Job Description

Job Description

Job Description

JOB DESCRIPTION

Position Title: Health Information Specialist

(Medical Records Specialist)

Department: Medical Record Department

Reports to: Director of Health Information Manager

Supervises: N/A

Entry Level Qualifications:

High school graduate or equivalent with one (1) year general clerical/typing experience with some computer application. Experience in medical record services or health related field desired. Experience in ICD 9-CM coding desired. Knowledge of: Terminal digit filing; general clerical and typing functions; computer application; and, general office equipment operation. Familiarity with ICD 9-CM coding principles and addictions and psychiatric treatment desired.

Skilled in: General clerical and typing duties; standard office equipment operation; accurate typewriting/keyboarding
(45 WPM); and, word processing and data entry. Good organization, verbal, and written communication skills. Able to: Follow instruction; work independently as well as a team member; maintain confidentiality standards; and, pay attention to detail ensuring accuracy and completion of tasks. Possess personal characteristics associated with Company representation including professional appearance and demeanor.

1. Stand on a filing stool for approximately 30 minutes at a time.

2. Sit for approximately 5-7 hours per each 8-hour shift.

3. Stand for a period of up to 2 hours per each 8-hour shift.

4. Lift and carry manuals/books/files to 20 pounds.

5. Bend and stoop from standing position to floor.

6. Distinguish colors; 20/40 vision in each eye (corrected).

7. Hear clearly (hearing aid acceptable).

8. Continuously use telephone for a period of up to 2 hours per each 8-hour shift.

9. Continuously use computer for a period of up to 4 hours per each 8-hour shift.

10. If recovering, two (2) years of continuous verifiable abstinence.

General Responsibilities:

Performs medical record clerical duties, typing/data entry, filing and, based upon skill level/training/experience, assigns ICD 9-CM diagnostic and procedural codes; comply with established protocols, productivity standards and guidelines. Participate in Performance Improvement activities relative to medical record clerical functions.

Know and abide by the general provisions of 42 CFR Part 2, “Confidentiality of Alcohol and Drug Abuse Patient Records”; and 45 CFR
“Health Insurance Portability and Accountability Act”. This position has unrestricted access to patient health information.

Essential Functions:

Based upon skill level/training/experience:

1. Accurately complete clerical medical record functions within defined performance protocols, productivity standards and guidelines. Based upon demonstrated competency, functions to include: Daily admission and discharge tracking; chart assembly; concurrent and retrospective analysis; coding and data entry of diagnoses, procedures and other computer information; release of information;
incomplete chart counts; completion and maintenance of files, logs, registers, and indices; filing and retrieving medical records in accordance with approved policies and recognized standards of practices; logging in and filing of transcribed medical record reports; and, preparing records for off-site storage and microfilming and facilitate retrieval as needed.

2. Assists facility staff in medical record completion as necessary.

3. Participate in Performance Improvement activities as needed.

4. Assist in new employee orientation and continued staff training as needed.

5. As designated by and in the absence of the Medical Record Supervisor, serve as the "lead" Medical Record Specialist.

6. Must maintain a professional demeanor and appearance, must not appear impaired or disoriented, but rather must present coherent and articulate speech, kept appearance, alert, oriented, and responsive to patients' needs and concerns.

7. Other duties as assigned.

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