Northern Light Home Care and Hospice

Department: Health Information Management

Position is located: Cianchette Professional Blding

Work Type: Full Time

Hours Per Week: 40.00

Work Schedule: 8:00 AM to 5:00 PM

Summary:

The Medical Records Assistant is responsible for promoting and maintaining the integrity of the Home Care & Hospice's medical records. The incumbent utilizes critical thinking and problem solving skills to promote continuous quality improvement in the areas of documentation, record storage, release, retrieval and destruction. The Medical Records Assistant coordinates Home Care & Hospice's response to external requests for release of information in accordance with all state and federal regulations. Serves as a resource for agency staff and management in regard to above areas. The incumbent acts as a backup to reception as needed. Performance reflects the mission and values of Home Care & Hospice.

Responsibilities:

• Medical Records-Promotes and maintains the integrity of medical records; including storage, release, retrieval, and destruction.

• Scans and indexes all client documentation into the appropriate electronic record and in appropriate file within agency defined time frames.

• Reviews completeness of medical record of documentation including but not limited to date discrepancies, logical inconsistencies, and error upon admission and discharge from the agency, in accordance with State and Federal Regulations.

• Coordinates with clinical staff and management to correct identified problems and trends.

• Assists in preparing medical records for all regulatory survey related activities.

• Maintains electronic spreadsheet showing submission of documentation requests and appeals.

• Prepares packages for shipping/mailing, accurately certifying and tracking same.

• Maintains tracking of HIPAA disclosures of client records.

• Organizes and manages effective systems for tracking active and discharged records that are to be stored at the agency and off site.

• Retrieves and returns records to/from the agency's off site storage company.

• Coordinates the destruction of medical records in accordance with State and Federal guidelines.

• Processes release of information requests and other external review requests in accordance with State and Federal regulations regarding confidentiality of client information.

• Secures protected health information during non-business hours and in the event of a fire or fire drill.

• Maintains adequate inventory of medical record supplies.

• Assists in process for assembling admission packets for staff as needed.

• Physician Orders Management- Ensures the agency's compliance with State and Federal regulations in regard to timely physician signatures on orders and 485 plans of care.

• Prints and tracks 485 plans of care to ensure electronic signature by the clinical manager or clinician.

• Regularly reviews the Orders Audit to ensure timely mailing of physician orders.

• Tracks receipt of all physician orders, discharges and other relative medical record documentation.

• Frequently reviews outstanding orders by physician and date to vigorously seek order recovery.

• Enlists the assistance of supervisor and account representatives for orders from physicians not responsive to routine order processing strategies.

• Computer Processing- Demonstrates competency with excel, word processing, and clinical/administrative documentation software.

• Utilizes critical thinking and organizing skills to maintain integrity of data in area of responsibility

• Utilizes appropriate data entry systems.

• Utilizes Allscripts program proficiently for assigned medical records functions.

• Performs additional duties as required or assigned.

Other Information:

Competencies and Skills

• Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.

• Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.

• Demonstrates Adaptability: Learns quickly when facing a new problem or unfamiliar task; is flexible in their approach with changing priorities and ambiguity. Manages change effectively and does not give up during adversity. Capable of changing one's behavioral style and/or views in order to attain a goal. Absorbs new information readily and puts it into practice effectively.

• Demonstrates Emotional Intelligence: Exhibits a high level of self-awareness, self-management, other awareness and relationship management. Conducts themselves in an empathic, appropriate way, with a sense of humor and stimulates a collaborative work environment. Is respectful of the attitudes, feelings, or circumstances of others and aware of the influence of their own behavior on them. Is aware of relevant social, political, system, and professional trends and developments and uses this information for the organization's benefit.

• Develops Self and Others:Takes responsibility for engaging in professional self-development activities and programs. Strives to gain insight into their own values, strengths and weaknesses, interests and ambitions and takes action in order to enhance competencies and skills when possible. As a leader, encourages and guides employees towards growth opportunities to enhance performance and help them reach goals. Reviews and analyzes employees' strengths and weaknesses to distinguish their talents and development needs, and to ensure they are enhanced appropriately.

• Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences' level.

• Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.

• Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.

• Serves Others: Strives to understand, meet and exceed the expectations and requirements of internal and external customers which may include the people and communities in our service areas. Develops and maintains relationships, alliances and coalitions within and outside the organization and leverages them in order to obtain information, support, and promote cooperation and collaboration.

Education

• Required High School Diploma/General Educational Development (GED)

Working Conditions

• Need to drive to perform responsible duties.

• Work with computers, typing, reading or writing.

• Lifting, moving and loading 20 to 30 pounds.

• Prolonged periods of sitting.

• Alternate shift schedules (day, evening, nights, weekends).

Position Medical Records AssistantLocation Req ID null