MEDICAL RECORDS SPECIALIST

Job Duties

• Maintains inpatient and discharged patient health records to ensure accuracy, completeness and timeliness in compliance with regulatory agencies such as the Joint Commission, CMS, and files discharged charts into the terminal digit filing system.
• Completes chart audits of patient records, from admission, throughout hospitalization and upon discharge, according to department guidelines. Medical Records charts may consist of both paper and electronic documentation. Charts are audited for completeness and timeliness of documentation, to ensure compliance with regulatory standards.
• Retrieves documents from the patient units for scanning into the EHR. Examines documents to ensure that patient identification is on both sides of the document. Scans or imports documents into the EHR and examines them to ensure that both sides have been scanned and are oriented correctly. Assists with training of staff in the new EHR.
• Maintains patient health records according to hospital guidelines. Creates and maintains addendum folders according to prescribed format.
• Affords assistance in the verification process of discharge data by auditing discharged patient records for accuracy and completeness of information reported to the Joint Commission.
• Responds to requests for information from external review organizations. Redacts PHI from documents prior to distribution.
• Completes the Master Patient Index search accurately to determine prior admission history. Pulls previous admission record and brings it to the unit for clinical staff review.
• Other duties as assigned as related to the position (typically 5% - 10%)

Knowledge, Skills & Abilities (KSAs)

• Knowledge of:
• Medical terminology and anatomy.
• Accepted methods and techniques in maintenance of medical records.
• Laws, rules, and regulations regarding medical records.
• Medical record documentation standards as established by the Joint Commission, CMS standards, and state licensing regulations.
• Hospital rules and regulations relating to documentation requirements in the health record.
• HIPAA requirements for protected health information.
• Personal computer software (i.e. Word, Excel) as well as an electronic health record system.
• Performance Management (PM), and Continuous Quality Improvement (CQI) and Lean methodologies.
• Skill In:
• Interpersonal skills to interact with a variety of professional and para-professional staff, the patients, and the public.
• Oral and written communication.
• Detail-oriented.
• Skills in filing complex medical information and documents.
• Audit skills to determine the completeness and accuracy of medical record documentation.
• Computer skills in a variety of software packages applicable to medical records management.
• Time management skills
• Ability to:
• Maintain confidentiality.
• Accurately and efficiently file and scan documents.
• Concentrate for long periods of time.
• Use a variety of office equipment, i.e. fax, scanner, copier, computer, printer.

Pre-Employment Requirements

• Driver's License.
• State hospital employee must possess a valid level one fingerprint clearance card issued pursuant to A.RS. 41-1758.07 or must apply for a level one clearance fingerprint clearance card within seven working days after beginning employment.

Benefits

• Affordable medical and dental insurance plans
• Paid vacation and sick time
• 10 paid holidays per year
• Wellness program and plans
• Life insurance
• Short/long-term disability insurance
• Defined retirement plan
• Award winning Infant at Work program
• Credit union membership
• Transit subsidy
• ADHS Student Assistance Pilot Program

Retirement

• The State makes monthly contributions to finance your retirement benefit. The State will make a contribution to the ASRS in an amount equal to your contribution. In other words, you and the State will each pay 50% of the total cost of the benefit. New State employees have a 27 week wait period for contributions to begin.

Contact Us

• The State of Arizona is an EOE/ADA Reasonable Accommodation Employer. Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by calling (602) 542-1085. Requests should be made as early as possible to allow sufficient time to arrange the accommodation.