SUMMARY

Assists in management of medical records. 

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION AND/OR EXPERIENCE

• High school diploma or general education degree (GED).
• Prior experience or training in a medical records position preferred.

LANGUAGE SKILLS

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.  Ability to write routine reports and correspondence.  Ability to speak effectively on the telephone.

MATHEMATICAL SKILLS

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. 

REASONING ABILITY

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.  Ability to deal with problems involving several concrete variables in standardized situations.

PHYSICAL DEMANDS

Rarely = 0-15% of time, Occasionally = 16-45% of time, Frequently = 46-100% of time

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required:

• To talk, hear, stand, sit, walk, squat, twist, reach with hands/arms
• Problem solve, make decisions, read, write
• Use of computer and software systems
• Use other technical equipment (copier, fax, etc)
• To operate a telephone
• The ability to organize mental demands
• Interpret data

The employee is occasionally required:

• To operate a vehicle
• Occasionally lift and/or carry up to 40 pounds

The employee is rarely required:

• Shovel and mop

MARGINAL AND ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

MARGINAL JOB FUNCTIONS

Duties the employee performs that although important do not have as major an impact on the delivery of services to our clientele:

• Acting as a positive role model for the clients and other employees.
• Following through on directives given by a supervisor or other designated team leaders within the agency.
• Interacting with clients and families in a courtesy and professional manner.
• Keeping communication open between all levels of employees.
• Knowing and supporting the agency mission statement.
• Attending and participating on Agency committees as requested.
• The physical care of the facilities and agency equipment.
• Working as a member of a team including, being supportive and friendly to co-workers, keeping personal problems away from work, splitting duties equally amongst co-workers, assisting co-workers when requested and welcoming new employees giving then extra support and encouragement.
• Ensuring that files are organized and up-to-date.
• Making copies of documents as needed.
• Maintain safety and security of the premises.
• Maintains clean and orderly work area and equipment.   
• Attending and completing scheduled required annual training.
• Keeping communication open between all levels of staff.
• Maintains proper professional appearance.

ESSENTIAL JOB FUNCTIONS

Duties the employee is required to perform that have a major impact on the delivery of services to our clientele:

• Filing all agency information for active and discharge clinical records when necessary.
• Because some record keeping will be in a digital format, you are also expected to have knowledge of computers and software programs related to organizing and maintaining medical records.
• Enter data such as demographic information into the medical record database.
• Assembling of medical records for paper-based programs.
• Process patient admission or discharge documents.
• Analyzes active and discharge records for deficiencies according to regulatory agency criteria. Understands JCAHO standards to help assure H.I.M. meets these standards.  Notifies staff of deficiencies in a timely manner.
• Review records for completeness, accuracy, and compliance with regulations in a timely manner.
• Visionary scans permanent filing system on a regular basis for misfiled patient records to ensure accurate filing. 
• Scan active and/or closed charts to the network and EMR system as necessary. 
• Scan and/or upload information to the network for the programs that are paperless.   
• Scan third-party information to the EMR system as deemed necessary.
• Completes assignments independently and within expected time frames and is able to adjust to increased workload. 
• Purges patient records from permanent filing system on a periodic basis as requested.
• Aide in training medical records staff as needed.
• Release information to persons or agencies according to regulations.
• Retrieve, copy and/or fax patient records requested by our medical staff offices and or patient requests.
• Protect the security of medical records to ensure that confidentiality is maintained.
• Monitoring the sign out of clinical records.
• Traveling to assigned programs as deemed necessary.
• Transcribe (transcription) medical records when required.
• Performs other clerical and administrative duties as assigned or requested by supervisor in a helpful and cooperative manner.

COMPETENCY EXPECTATIONS

Must demonstrate during training period, first 90 days of employment, competencies in the following areas:

1. Assembling of Patient Medical Record

2. Purging Medical Records

3. Active Medical Record review

4. Discharge Medical Record review

5. Release of Patient Information

6. Working knowledge of EHR system

WORK ENVIRONMENT

Rarely = 0-15% of time, Occasionally = 16-45% of time, Frequently = 46-100% of time

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently:

• Working indoors

The employee is occasionally required to:

• Be exposed to individuals who have the potential to be hiv-positive, have hepatitis or other communicable diseases. 
• Exposed to clients that who are court ordered to attend treatment.
• Exposed to clients who have a mental health diagnosis or intellectual developmental disability, which might include: attention deficit/ hyperactivity disorder, anxiety disorder, conduct disorder, oppositional defiant disorder, borderline personality disorder, borderline intellectual functioning, depression, dysthymia, bipolar disorder. 
• Drive/Operate a vehicle and travel to meetings, etc.

The employee is rarely required to:

• Work outdoors
• Work around loud noises
• Work around hot/cold temperatures
• Work around fumes

AGENCY EXPECTATIONS

Employees are expected to:

1. Preserve the positive public image of the agency and its employees.

2. Be familiar with Agency's Policy and Procedure Manuals and function within the directives provided.

3. Be aware of and follow state regulations.

4. Report to administration any situation that interferes with proper operation of the agency.

5. Report to administration any actions by another employee which may constitute possible emotional or physical abuse.

6. Maintain a confidential attitude in regards information pertaining to the individuals we serve.

7. Maintain high clinical quality and a safe environment within the Agency.

TRAINING REQUIREMENTS

This position requires participation in ongoing mandatory trainings while employed.  Training requirements are detailed in the Training Matrix which is maintained by the Human Resources Department.  Along with their supervisor, each staff person is responsible for reviewing the Training Matrix to determine individual training requirements and completing those requirements in a timely manner. 

SUPERVISORY RESPONSIBILITIES

This position does not directly supervise any employees.

PHYSICAL/HEALTH ASSESSMENT REQUIREMENTS

This position is required to have a pre-employment physical.

TRAVEL REQUIREMENTS

This position requires an active driver's license and a DMV check that is clear.  Position may require travel in the communities served or state of Pennsylvania for position requirements 10-15% of the time. 

OTHER DUTIES

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

I have read the above job description. I understand the duties and expectations that will be required of me. I affirm that I have the physical and emotional capability to complete what is expected of me.

Employee Signature:    ______________________________________

Date:    ______________________________________

Human Resource Representative:    ______________________________________