• Receives and processes all requests for health records from file area after consumers’ discharges.
• Reviews and analyzes medical records for accuracy, completion, and timeliness of documentation.
• Assembles record in chronological order during review, and prepares record for imaging.
• Checks and documents all chart deficiencies: for nurses, doctors, therapists and behavioral staff (Inpatient), and completes Administrative Reviews (Outpatient).
• Correctly categorizes deficiencies based on color coding system in use.
• Obtains all missing information and corrects all deficiencies in records within standard compliance timeframes.
• Protects and maintains the confidentiality of all records and patient information.
• Maintains the chart tracking (charge-out) system to track the location of each record.
• Assists clinicians with pulling and locating charts.
• Sorts incoming charts and ensures they are routed to the proper location and clinician.
• Ensures charts are filed back promptly by the end of each workday.
• Completes and processes authorizations to release of information as requested.
• Answers the telephone in a professional manner using 5 Star Customer Service standards.
• Orders, maintains, and distributes AltaPointe approved forms.
• Assists in purging records for destruction on a regular basis.
• Adheres to program specific procedures and protocols as outlined by the Assistant Coordinator of Health Information.

Supervision and consultation:

• Seeks supervision and consultation as needed
• Accepts and employs suggestions for improvement
• Actively works to enhance skills.

• Treats consumers with care, dignity and compassion.
• Respects consumers’ privacy and confidentiality.
• Works in a cooperative manner with other AltaPointe employees.
• Assists consumers and visitors as needed.
• Personal values don’t inhibit ability to relate and care for others.
• Is sensitive to the consumers’ needs, expectations and individual differences.
• Is gentle and calm with consumers, families, and others as appropriate.

Administrative:

• Actively participates in Performance Improvement activities.
• Actively participates in AltaPointe committees as required.
• Completes assigned tasks in a timely manner.
• Follows AltaPointe policies and procedures.
• Attends appropriate in-service training and other workshops.
• Other duties as assigned.

Physical Requirements of the Job:

• Continuous sitting (extended sitting) up to 2 hours at a time until break or lunch.
• Reaching forward to place paperwork on a document stand.
• Grasping to turn keys in doors throughout facility, grabbing files/paperwork.
• Lifting up to 10 pounds.
• Carrying up to 10 pounds to transport small quantities of charts various distances in facility.
• Fine manipulation/dexterity for data entry, writing and handling paperwork
• Standing and walking frequently throughout shift and to various locations in the facility to file charts and put up supplies.
• Sitting can be in frequent bursts up to 10 minutes.
• While filing in the medical records department, the employee may bend forward, squat, lunge, stoop or crouch to access the levels that are at floor to waist level.
• Forward reaching, reaching out to front, and overhead reaching with up to 5 to 15 pounds is performed when filing records and charts.

High school graduate or the equivalent; two to three years’ experience in a medical records department or health care office setting; knowledge of medical and psychiatric terminology; ability to communicate verbally, withstand continual deadlines, concentrate and maintain accuracy in spite of frequent interruptions; detailed oriented and highly organized; knowledge of the following must be demonstrated within 6 months of hire:

• Understanding of documentation requirements and procedures in compliance with key agencies that include, but are not limited to, CMS, DMH and The Joint Commission
• Basic clerical skills including Microsoft Office, and the principles of alphabetic, numeric, and terminal digit filing
• Use of standard office equipment including copy machines and fax machines, and
• General EHR and medical records procedures and standards.