Medical Records Specialist - Corporate HIM

Medical Records Specialist - Corporate HIM - Full Time

Position Summary:

Responsible for the integration and quantitative analysis of discharged patients’ medical records. Account for and assemble the record of each patient; scan paper versions of legal portions of the medical record into the electronic record, indexing documents appropriately; review documentation for completeness and enter deficiencies into the provider’s queue. As needed, abstract data and enter charges into computerized files. As needed, transcribe the following report types: history and physical examination, consultation, record of operation, pathology, discharge summary.

Functions pertain to records for the following patient types: inpatient, observation, ambulatory surgery and certain outpatient procedures, emergency department.

High school diploma or equivalent required.

Experience with a windows based computer environment. Previous HIM experience preferred. Previous experience as medical transcriptionist is preferred.

• Account for all records for the date of service.
• Assemble any paper documents for a given patient, determining which are to be integrated into the electronic record.
• If not already in place, affix labels with patient identification on documents that are parts of the legal medical record.
• Scan and index documents appropriately, interface with the electronic record.
• Analyze record for missing elements, including reports and signatures; enter deficiencies into Epic Health Information Management module.
• As needed, assist providers with completion of the legal medical record and remove deficiencies from tracking system.
• As directed, abstract data and enter charges into the appropriate computer system.

As needed, respond to requests for medical records, disclosing information only as authorized to do so. As needed, transcribe the following report types: history and physical examination, consultation, record of operation, pathology, discharge summary. Participate in departmental quality monitoring. Perform other duties as assigned.

$17.00 - $22.37/hour, DOE

• Entry level

• Full-time

• Health Care Provider

• Hospitals and Health Care

Location:

Endicott, NY