Under general supervision and in accordance with established policies and procedures, analyzes charts for accuracy, consistency and completeness according to hospital and regulatory agency guidelines. Reviews and processes request for subpoenas received from outside providers, agencies, schools, and attorneys in compliance with applicable state laws. Performs a variety of clerical duties related to the processing of medical records. Essential Responsibilities:Upholds Kaiser Permanentes Policies ... more details
Description:
Job Summary:
Under general supervision and in accordance with established policies and procedures, analyzes charts for accuracy, consistency and completeness according to hospital and regulatory agency guidelines. Reviews and processes request for subpoenas received from outside providers, agencies, schools, and attorneys in compliance with applicable state laws. Performs a variety of clerical duties related to the processing of medical records.
Essential Responsibilities:
Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities and applicable state, federal and local laws. Depending on the area/unit assigned, an employee in this classification may be assigned duties in any one or more of the following major functional areas.
RECORD ANALYSIS and CONTROL Conducts initial analysis on all types of medical reports to verify completeness by reviewing entire medical record. Ascertains deficiencies according to standards established by the Medical Records encompassing requirements of other accreditation and licensing agencies. Notes deficiencies for physicians review and notes missing information directing it to the appropriate personnel for completion. Performs periodic audits to detect and address delinquent outliers. Notifies appropriate personnel by mail, phone, or via electronic communication of information or items required in order to complete the records; identifies the urgency for providing the requested items. Assists and/or advises physicians and others regarding the records completion process. Assists in problem solving. Responsible for compiling and/or completing delinquent medical records count, manually and/or via computer systems, including but not limited to: verifying delinquent medical records, preparing and mailing physician notification letters, maintaining logs, and reports. Performs qualitative audits of records as directed. Establishes and maintains courteous, cooperative relations when interacting with all agencies, members, medical center personnel, department personnel and the public. May perform other duties as assigned.
DEATH CERTIFICATE/BIRTH CERTIFICATE/FETAL DEATH CERTIFICATE PROCESSING Completes and processes a birth certificate for each live birth within required time frames. Prepares death certificates and fetal death certificates for physician signature and mortuary pick up Screens charts for Coroners cases. Maintains expiration logs. Sends timely notices of expiration to designated parties. Trains new employees. Establishes and maintains courteous, cooperative relations when interacting with all agencies, members, medical center personnel, department personnel and the public. May perform other duties as assigned.
ABSTRACTOR Verifies and abstracts demographic and/or clinical data from patients charts. Enters data into automated abstracting/encoder systems. Trains new employees. Establishes and maintains courteous, cooperative relations when interacting with all agencies, members, medical center personnel, department personnel and the public. May perform other duties as assigned.
MEDICAL INFORMATION REQUESTS/SUBPOENAS Reviews requests and subpoenas received from members, outside providers, agencies, schools and attorneys. Verifies that proper authorizations are obtained in compliance with all regulatory agencies and applicable laws. Orders medical records, obtains missing authorizations and verifies that appropriate information is in the record. Interviews and assists appropriate individuals to ascertain their release of information needs. Determines urgency of request and appropriate procedure to facilitate requests. Abstracts or prepares patient charts to obtain specific medical data. Prepares form letters or designated forms to provide specific information requested. Maintains logs, manually or by computer, of all Release of Information requests received for tracking of all requests, including ensuring the Disclosure Accounting functions for HIPAA is completed. Initiates requests for medical information by completing medical request forms, mailing to appropriate agency or physician, and following up when request is not answered within a designated time frame. Collects and processes any applicable fees for providing the information. Meets legal time frames for making records available. Trains new employees. Establishes and maintains courteous, cooperative relations when interacting with all agencies, members, medical center personnel, department personnel and the public. May perform other duties as assigned.
MEDICAL TRANSCRIPTION Performs a variety of clerical duties in support of the Medical Transcription function. Sorts and distributes transcribed reports. Correlates charts with transcribed reports. Gathers missing identification data; types missing data onto the transcribed reports; flags reports for physician attention if lacking any or all information; obtains physician signatures for dictations. Assigns STAT dictations to the appropriate outside services and/or in house personnel for transcribing. Follows up on problem dictation for completion and/or redictation. Assists in the operation of the overall central dictation system by locating missing dictation, maintaining all computer systems; alerting appropriate parties of urgently needed reports/dictation. Responds to inquiries regarding dictated reports. Delivers transcribed data to appropriate areas. Maintains communication with transcription companies utilized for outsourced dictation. Trains new personnel. Establishes and maintains courteous, cooperative relations when interacting with all agencies, members, medical center personnel, department personnel and the public. May perform other duties as assigned.
Pay Grade 14
Basic Qualifications:
Experience
Proof of Medical Terminology course completion Two (2) years hospital Medical Record experience 45 wpm or as required by facility
Education
Proof of Medical Terminology course completion.
License, Certification, Registration
N/A
Additional Requirements:
Preferred Qualifications:
Registered Health Information Technician ( RHIT)
Notes:
Position may require to work weekends, per operational need
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