Job Summary: Evaluates, analyzes and monitors the patient’s medical record for compliance with licensing, regulatory and accrediting agencies, as well as medical staff rules and regulations. Also is responsible to analyze charts of same day surgery, recurring and acute care patients to maintain a high quality of accuracy and productivity. Abstracts clinical information into information system as outlined in departmental policies.

Shift: Day

Demonstrates Competency in the Following Areas:

· Collects patient records from appropriate locations on a daily basis.

· Scans records to appropriate medical record and form ID

· Analyzes medical records for completeness and accuracy according to Department and Hospital policy and procedures as the hospital’s accrediting body, CMS and state and other regulatory requirements.

· Abstracts clinical data with an accuracy rate of 98%.

· Enters deficiencies into computer for completion.

· Removes deficiencies when complete

· Release protected health information adhering to all applicable laws and regulations

· Performs QC of records scanned for accuracy

· Collects EKGs, maintains log and scans into medical record

· Assists with backup coverage of the window

· Is familiar with all charting requirements, including newborn, pediatric, adult and swing requirements.

· Preps records for scanning, placing batch cover sheets with appropriate chart and organizing charts in orderly manner

· Keeps up with workload. Must remain current

· Maintains log of missing medical records and follows up timely

· Indexes records after scanning

· Maintains error rate of %5 or less

· Assists in answering the telephone and taking accurate messages.

· Communicates regularly with supervisor on problems, issues or concerns in his/her section.

· Maintains a good working relationship within the department and other departments.

· Completes annual education requirements.

· Reports to work on time with minimal absenteeism.

· Consistently completes and maintains assigned duties.

· Maintains hospital requirements on confidentiality.

· Willingly accepts additional assignments.

· Adheres to dress code; appearance is neat and clean.

Education/Regulatory Requirements & Experience:

· Associates Degree in related field preferred

· Three months related experience.

· Previous work history that demonstrates steady attendance and punctuality is required.

Language Skills:

· Ability to read and communicate effectively in English.

Skills:

· Basic clerical ability with an overall score of 80%

· Basic keyboard skills

· Typing speed of at least 30 wpm

· Knowledge of scanner preferred

· Medical terminology.

Physical Demands:

· For physical demands of position, including vision, hearing, repetitive motion and environment, see following description. Near visual & hearing acuity required to perform essential duties of position.

· Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.