Job Description: Medical Records Coordinator

Reports To:  Clinical Manager

Department: Clinical

Position Summary

Overall responsibility for ensuring the medical records functions meet State and Federal Regulatory guidelines, and complies with agency policies and procedures. Ensures the duties are completed in a timely and proper manner, either by performing the duties, or by coordinating with any Medical Records Clerk(s), as staffed.

Position Qualifications:

• High School graduate or equivalent. Associate’s or more advanced degree preferred.
• One year experience in a medical office, hospital, outpatient clinic, or other health care settings.  Home health or hospice experience preferred.
• Knowledge of medical terminology
• Minimum of one-year medical coding experience with knowledge of CPT and HCPCS coding
• Computer literacy
• Intermediate typing skills
• Knowledge of office machines
• Excellent phone skills with an emphasis on customer service
• Organizational skills

Duties:

1. Ensures all medical documentation is filed in the patient’s closed and/or open clinical records (hard copies and computer records) in a proper and timely manner
2. Conducts ongoing quality assurance activities with all medical records in department to ensure accuracy and completeness of clinical records processing
3. Develops organizational tools to facilitate and incorporate accountability for all medical records
4. Identifies and informs supervisor of discrepancies if found related to the medical records functions requiring completeness and regulatory compliance, and if discrepancies are discovered develops immediate corrective actions to meet the state and federal regulatory requirements for accuracy and completeness.
5. Takes initiative to enhance record department procedures and capabilities
6. Ensures all physician verbal orders and other orders received via facsimile (to include Plans of Care, Certificates of Terminal Illness) are signed by the appropriate ordering physician, and provides follow-up for all missing and unsigned paperwork.
7. Ensures safeguarding of medical records in accordance with the Privacy Act. Maintains HIPAA compliance regarding any patient and agency records.

8. Audit for completion and close discharged patient records within 14 days of discharge per agency procedure ensuring all documentation is complete and all documents are signed and dated by the appropriate discipline.
9. Provides medical record information, to include computer generated data, to all staff as necessary
10. Prepares and transmits basic correspondence, uses office equipment
11. Answers the phone and directs phone calls appropriately
12. Performs other duties as assigned
13. Will participate in Quality Assurance Performance Improvement as required
14. Insurance verification on referrals

Contacts:  Families, volunteers, staff members, hospital/facility personnel, the general public.

Physical Demands: Physical exertion—walking, lifting, pulling, computer work

Environmental Conditions: Exposed to products used in the office, i.e, printers, computers, dust, etc.

Working Conditions: Periods of stress—variable workloads and deadlines

HomeCare & Hospice of the Valley is an equal employment opportunity employer committed to non-discriminatory employment practices and patient services.

Non-exempt position

May 2013