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Medical Records Clerk

Medical Records Clerk

St. Josephs Medical CenterHouston, TX, US
5 days ago
Job type
  • Full-time
Job description

Job Description

Job Description

JOB SUMMARY :

This position works collaboratively with employees in the Health Information Management Department, the clinical departments, Quality, Utilization, and Risk Management Departments, Medical Staff Office, Patient Access, and members of the Medical Staff to ensure that patient medical records contain accurate and reliable information in accordance with DNV and CMS Standards, hospital guidelines, medical staff bylaws, and state and federal regulations. Typical shift will be onsite Monday - Friday for 8 hours with 30-minute lunch and two 15-minute breaks. Work week typically consists of 40 hours. Depending upon the needs of the HIM department this position could be required to work varying hours on any day of the week.

PRINCIPAL DUTIES AND RESPONSIBILITIES :

  • Consistently supports and communicates the Mission, Vision and Values of St. Joseph Medical Center.
  • Follows the St. Joseph Medical Center Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
  • Promotes a culture of safety for patients and employees through proper identification, proper reporting, documentation, and prevention of medical errors in a non-punitive environment.
  • Supportive of the compliance program set forth by SJMC and demonstrated by :

Upholds the Code of Ethics and Corporate Compliance.

  • Adheres to dealing appropriately and fairly with employee misconduct.
  • Enforces all compliance policies as they pertain to his / her area.
  • Provides and assures timely compliance education as requested by the Compliance Officer and / or through corporate initiatives.
  • This position requires collection, prepping, scanning, and indexing of a patient's medical record.
  • Collecting requirements :
  • Collects all discharged patient medical records from the patient care units daily.

  • Completes collecting of all discharge records and reconciliation of discharge report in a timely manner meeting the productivity standard set by department.
  • Prepping requirements :

  • Prep all records for production into the Electronic Medical Record, including but not limited to inpatient, outpatient, emergency, ancillary, recurring, and loose documents.
  • Review and organize medical record documents in the correct order (e.g., by document type, date)
  • Prepares the paper medical record for scanning. Includes removing staples, rubber bands or paper clips, looking up and assigning account numbers, unfolding and taping medical recording strips, and straightening wrinkled paper to ensure smooth document scanning.
  • Ensure all pages are legible and contain proper patient identifiers.
  • Completes batch cover sheet for each medical record.
  • Scanning requirements :
  • Scans documents into the Electronic Medical Record (Meditech) in a timely manner meeting the productivity standard set by department.

  • Indexing requirements :
  • Performs quality check on scanned images.

  • Accurately indexes all images. Indexes documents to correct encounter and document type.
  • Works Indexing Queues. Reviews assigned work queue(s) daily and ensures timely processing of all assignments in the queues. Writes each indexed batch to the appropriate queue according to workflow procedure.
  • Files chart after completion of indexing function.
  • Accounts for all discharge charts. Researches and retrieves any discharged chart not retrieved by prep and scan technicians.
  • Performs indexing functions in a timely manner meeting the productivity standard set by department.
  • Other requirements :
  • Good computer and software skills including but not limited to email, MS Word and MS Excel.

  • Reviews assigned work queue(s) daily and ensures timely processing of all assignments in the queues.
  • Records each indexed batch to the appropriate queue according to workflow processes.
  • Monitors supply usage in area and reports supply needs to the HIM Coordinator-Forms Designer for order. Ensures adequate supplies are maintained for area.
  • Analyzes medical records of discharged patients for completeness and accuracy according to departmental policy, hospital Bylaws, Rules and Regulations, and regulatory agencies as requested. (Reference Analysis Productivity Standards for hourly productivity requirements.)
  • Assists Nursing Supervisor with Release of Information on weekends if required.
  • Assist with preparing Fetal Monitor strips.
  • Assist with Retrieval and Filing of Records.
  • Assists with special projects as requested.
  • Sets an example to all staff in their daily activities.
  • Demonstrates teamwork, accountability, and ownership.
  • Good communications skills; able to work in a team or independently.
  • Demonstrates the ability to be flexible and complete other tasks as needed or requested by the Operations Manager or HIM Director.
  • MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED :

    WORK EXPERIENCE :

  • Medical record assembly experience preferred.
  • Computer experience required.
  • Experience in Meditech.
  • EDUCATION & TRAINING :

  • Ability to read to perform functions outlined in principal duties and responsibilities as typically acquired through completion of high school diploma or equivalent.
  • Medical terminology, preferred.
  • SKILLS :

  • Command of the English Language
  • Excellent communication skills both written and oral to explain medical record requirements to others and answer telephones.
  • Computer experience includes email, MS Office, and MS Excel.
  • Ability to perform repetitive tasks with high level of accuracy and attention to details.
  • Ability to solve problems independently.
  • Ability to work independently and as part of the HIM Team
  • Good analytical skills for performance of indexing functions, analysis, and quality control reviews
  • Terminal digit filing
  • Chart format.
  • Chart workflow.
  • Houston's oldest hospital is GROWING!

    Welcome to St. Joseph Medical Center (SJMC), Houston's first and only downtown hospital delivering world-class care for the last 137 years and looking forward to the next century of exceptional care to Houstonians when they need us most.

    Whether it's for a scheduled surgery, the birth of a baby, an unexpected emergency, or an outpatient visit, we have staff available around the clock to provide you access to immediate, quality health care. SJMC has been providing health care services to Greater Houston residents for over 130 years, which should give you great comfort in knowing that we have a great tradition of caring for our community. We strive to meet our patients' expectations and encourage our patients to provide us with feedback on how we can help them have the best experience possible while they're in our care.

    Over the last years we have expanded our services to include the Advanced Wound Care Center, Comprehensive Cardiac and Vascular Services, the Women's Center, the St. Joseph Maternal Fetal Medicine Center, and a Weight Loss Surgery Program, just to name a few. As you work with our physicians, nurses, case managers, educators, and other staff, you will be guided through your health care journey, from diagnosis to treatment, with compassion every step of the way.

    Diversity, equity, inclusion, and belonging are at the foundation of the care St Joseph Medical Center provides to our community we are privileged to support in all of our employment practices. We do not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or expression or any other non-job-related characteristic.

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