Under general supervision and in accordance with established policies and procedures, analyzes charts for accuracy, consistency and completeness according to hospital and regulatory agency guidelines. Reviews and processes request for subpoenas received from outside providers, agencies, schools, and attorneys in compliance with applicable state laws. Performs a variety of clerical duties related to the processing of medical records.
Essential Functions:
Upholds Kaiser Permanente's Policies & Procedures, Principles of Responsibilities and applicable state, federal & local laws.- Depending on the area/unit assigned, an employee in this classification may be assigned duties in any one or more of the following major functional areas.
- Records Analysis & Control: Conducts initial analysis on all types of medical reports to verify completeness by reviewing entire medical record.
- Ascertains deficiencies according to standards established by the Medical Records encompassing requirements of other accreditation & licensing agencies.
- Notes deficiencies for physicians review & notes missing information directing it to the appropriate personnel for completion.
- Performs periodic audits to detect & address delinquent outliers.
- Notifies appropriate personnel by mail, phone or via electronic communication of information or items required in order to complete the records.
- Identifies the urgency for providing the requested items.
- Assists and/or advises physicians & others regarding the records completion process.
- Assists in problem solving.
- Responsible for compiling and/or completing delinquent medical records count, manually and/or via computer systems, including but not limited to: verifying delinquent medical records, preparing & mailing physician notification letters, maintaining logs & reports.
- Performs qualitative audits of records as directed.
- Establishes & maintains courteous, cooperative relations when interacting w/ all agencies, members, medical center personnel, department personnel & the public.
- May perform other duties as assigned.
- Death Certificate/Birth Certificate/Fetal Death Certificate Processing: Completes & processes a birth certificate for each live birth w/ in required time frames.
- Prepares death certificates & fetal death certificates for physician signature & mortuary pick up.
- Screens charts for Coroner's cases.
- Maintains expiration logs.
- Sends timely notices of expiration to designated parties.
- Trains new employees.
- Establishes & maintains courteous, cooperative relations when interacting w/ all agencies, members, medical center personnel, department personnel & the public.
- May perform other duties as assigned.
- Abstractor: Verifies & abstracts demographic and/or clinical data from patient's charts.
- Enters data into automated abstracting/encoder systems.
- Trains new employees.
- Establishes & maintains courteous, cooperative relations when interacting w/ all agencies, members, medical center personnel, department personnel & the public.
- May perform other duties as assigned.
- Medical Information Request/Subpoenas: Reviews requests & subpoenas received from members, outside providers, agencies, schools & attorneys.
- Verifies that proper authorizations are obtained in compliance w/ all regulatory agencies & applicable laws.
- Orders medical records, obtains missing authorizations & verifies that appropriate information is in the record.
- Interviews & assists appropriate individuals to ascertain their release of information needs.
- Determines urgency of request & appropriate procedure to facilitate requests.
- Abstracts or prepares patient charts to obtain specific medical data.
- Prepares form letters or designated forms to provide specific information requested.
- Maintains logs, manually or by computer, of all Release of Information requests received for tracking of all requests, including ensuring the Disclosure Accounting functions for HIPAA is completed.
- Initiates requests for medical information by completing medical request forms, mailing to appropriate agency or physician & following up when request is not answered w/ in a designated time frame.
- Collects & processes any applicable fees for providing the information.
- Meets legal time frames for making records available.
- Trains new employees.
- Establishes & maintains courteous, cooperative relations when interacting w/ all agencies, members, medical center personnel, department personnel & the public.
- May perform other duties as assigned.
- Medical Transcription: Performs a variety of clerical duties in support of the Medical Transcription function.
- Sorts & distributes transcribed reports.
- Correlates charts w/ transcribed reports.
- Gathers missing identification data.
- Types missing data onto the transcribed reports.
- Flags reports for physician attention if lacking any or all information.
- Obtains physician signatures for dictations.
- Assigns STAT dictations to the appropriate outside services and/or in house personnel for transcribing.
- Follows up on problem dictation for completion and/or redictation.
- Assists in the operation of the overall central dictation system by locating missing dictation, maintaining all computer systems.
- Alerting appropriate parties of urgently needed reports/dictation.
- Responds to inquiries regarding dictated reports.
- Delivers transcribed data to appropriate areas.
- Maintains communication w/ transcription companies utilized for outsourced dictation.
- Trains new personnel.
- Establishes & maintains courteous, cooperative relations when interacting with all agencies, members, medical center personnel, department personnel & the public.
- May perform other duties as assigned.
Pay Grade: 14
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Basic Qualifications:
Two (2) years hospital Medical Record experience.
Registered Health Information Technician (RHIT) preferred.
Proof of Medical Terminology course completion.
45 wpm or as required by facility.
Notes:
This position requires to work alternate weekends per operational needs.
PrimaryLocation : California,Baldwin Park,Baldwin Park Hospital
HoursPerWeek : 40
Shift : Day
Workdays : Sun, Mon, Tue, Wed, Thu, Fri, Sat
WorkingHoursStart : 08:30 AM
WorkingHoursEnd : 05:00 PM
Job Schedule : Full-time
Job Type : Standard
Employee Status : Regular
Employee Group/Union Affiliation : B01|SEIU|Local 399
Job Level : Individual Contributor
Job Category : Administrative & Support Services
Department : Baldwin Park Med Center - Health Info Mgmt Services - 0801
Travel : No
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.
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