Cert. Medical Records Specialist

POSITION SUMMARY

Responsible for supervising health records staff at all sites and for managing the health records department in compliance with all applicable standards, policies and procedures.

JOB RELATIONS

Responsible to	Health Services Administrator
workers supervised	Medical records staff
Inter-Relationships	Inter-relates and work effectively with patients, medical and nursing staff, security staff at all levels, administrative and support staff, and consulting physicians.

DUTIES/RESPONSIBILITIES

1. Oversee the daily operations of the medical records department.
2. Ensure that a medical record is maintained on each inmate in a confidential and secure manner.
3. Ensure that all facility and Wexford Health contractual agreements in regards to medical records are met.
4. Pre-audit and prepare medical records for monthly and/or quarterly reviews.
5. Address all court/legal-related correspondence as it relates to health records in a timely manner and in accordance with policies and procedures.
6. Attend court proceedings as the medical records custodian when necessary.
7. Participate in the Quality Improvement program by attending meetings and reporting on data assigned for collection.
8. Collect and submit information for monthly statistical reports.
9. Communicate with departments within the institution on issues related to the health records department.
10. Develop employee improvement programs, orientation programs and health records in-services for staff orientees.
11. Familiarize self with all rules, regulations, statutes, policies and procedures governing the health record.
12. Review/revise the health care record policy and procedures annually.
13. Conduct employee performance evaluations on employees under supervision.
14. Develop and implement corrective action plans to address health records contract audit issues.
15. Arrange for manual tracking of patients who require histories and physicals, and convey this information to the Health Assessment nurse/charge nurse/head nurse.
16. Assign staff members to routinely review health records for signature/name stamp, deficiencies and reports non-compliance of health care providers
17. Ensure that all forms contained in the health records are approved.

 

Employees may be assigned other duties as required.

PHYSICAL DEMANDS

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.

 

Essential duties are routinely performed in a general office and clinical environment.  Duties may require work in at a station/desk and entail paperwork, use of computers, fax machines, copiers, and other business machines and medical equipment.  Essential duties may require the following physical demands: the strength to lift and carry material weighing up to 30 pounds; vision to read printed materials and computer screen; walking; reaching; carrying; stooping; bending; squatting; prolonged sitting; handling (hand movement); hearing and speech to communicate in person and over the telephone; intellectual skills including short and long term memory, abstract reasoning, and decision making.

 

Must be able to ambulate throughout the facility for extended periods of time; specific vision abilities required by this job include close vision and distant vision, color vision, peripheral vision, depth perception, and the ability to adjust focus; must be able to clearly communicate orally and via written and typed correspondence and notes using various forms, records, charts, and electronic media.

Employee may be exposed to a challenging environment, which may include exposure to Bloodborne and Airborne Pathogens, and loud noises.

 

This position may require working non-traditional hours.  The incumbent is subject to both voluntary and mandatory additional hours worked. 

 

ENVIRONMENTAL CONDITIONS

Office	Standard medical setting in a correctional facility, which includes daily interfacing with inmates, correctional staff, and health care personnel. Temperature extremes may be encountered while moving throughout the facility outdoors and indoors in buildings without air conditioning.
Travel	None

 

 

Job Requirements:

EDUCATION/EXPERIENCE REQUIREMENTS

Licensing	None required.
Certification	Registered Health Information Technician (RHIT) required, Registered Health Information Administrator (RHIA) preferred.
Education	Associate’s degree from a Health Information Management program required.  Bachelor’s degree or above preferred.
Preferred experience	3 years’ previous medical records supervisor experience; correctional experience preferred.
Other preferred knowledge, skills and abilities	Strong interpersonal skills. Strong verbal and written communication skills. Typing skill of 50 words per minute. Proficiency in Microsoft Word, Power Point, and Excel.  Microsoft Access a plus. General math and analytical skills, and planning, administrative and organizational skills essential.  Ability to competently manage multiple priorities simultaneously. Ability to work in a stressful environment. Ability to maintain confidentiality.

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