Description

Position Summary:
A Medical Records Practitioner is responsible for serving as assistant to a professional superior, or an administrator in charge of medical records for the department of hospitals. Emphasis of the work is on completion of more difficult, specialized, qualitative review and evaluation of records, and completion of specialized assignments such as development of secondary records. Incumbents exercise considerable technical knowledge of medical nomenclature and terminology; varied accreditation requirements; and a high degree of accuracy in evaluating diversified medical records to ensure internal consistency and completeness. Resourcefulness and judgment are also exercised in dealing with the hospital staff in explaining and obtaining adherence to detailed clinical record requirements. Incumbents work with considerable independence, following established hospital policies and procedures, and technical standards. Work is reviewed by a technical superior who evaluates completed work on a spot check basis.

Duties & Responsibilities:
Assures that all admissions determined to be Medical Examiner Cases are labeled on medical records as such, and informs the facility Administrator and Director of Nursing. Assures that strict adherence to Laws of confidentiality of patient medical records; controls release of medical information; complies with new regulatory demands regarding confidentiality (e.g. HIV testing), as information is provided by Consultant. Completes statistical research reports of data collected manually and/or by computer system to identify trends; informs Administrator and Director of Nursing of findings. Presents reports to applicable staff; generates reports requested by Administration and/or other departments for their use as needed. Prepares and updates policies and procedures as needed. Assures that policies and procedures are adhered to. Completes special assignments such as abstracting patient medical records for Florida Hospital Cost Containment Reports on a quarterly basis. Serves as Record Management Liaison for the facility; responsible for scheduling record series, preparing records for storage at remote sites, completion of necessary reports and preparing additional reports when records are eligible for destruction. Provides in-service to other departments within facility for Records Management procedures. Initiates policies and proceed uses based on Federal and State Laws to assure facility compliance. Releases information to physicians, accredited representatives of insurance companies and others; as required, represents facility in court cases involving subpoena of clinical/medical records. Performs other related duties as assigned by the Administrator. Assures that timely completion of Master Patient Index, Admission/Discharge Register, Initial Utilization Review Card and Final Diagnosis Index is done. Provides technical assistance to Medical Record Practitioner 1 in abstracting of Admission ICD-9-CM codes and CPT-4 codes, chart assembly, filing and evaluation of clinical/medical records. Assures the promptness of patient data and medical transcriptions dictated by Advanced Registered Nurse Practitioner, Attending Physicians and Physical Therapist to the patient medical records. Supervises Medical Record Practitioner 1 in various record functions and current accreditation requirements (admission, coding, filing, abstracting and correspondence). Provides day to day direction to Health Services Representative II responsible for coordination of the resident pre-admission screening process, resident registration and admission procedure. Supervises Medical Data Support Technician and Health Records Analyst who are responsible for retrieval of medical data from patient medical records and verification, abstracting and entering patient medical data for a health care facility computer system. Completes qualitative analysis of complex clinical/medical records and discusses deficiencies with superior for referral to physicians for corrective action; discusses requirements directly with physicians and appropriate staff. Attends meetings and seminars within the community for professional development and medical record accreditation requirements. Coordinates Externship training for medical record students attending Miami-Dade Community College and Florida International University. Allocates adequate resources commensurate with authority to assess and improve services provided. Serves as Records Custodian for the facility. Performs other related duties as assigned. Role models behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). Performs all other related job duties as assigned.

Qualifications

Experience:
Generally requires 1 to 3 years of related experience.



Education:
High school diploma is required.

License Certification:
Valid license or certification is required as needed, based on the job or specialty.



Knowledge Skill Abilities:
Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines. Ability to communicate effectively in both oral and written form. Ability to handle difficult and stressful situations with professional composure. Ability to understand and follow instructions. Ability to exercise sound and independent judgment Knowledge and skill in use of job appropriate technology and software applications.

Physical Demands:
Job function is sedentary in nature and requires sitting for extended periods of time. Function may require frequent standing or walking. Must be able to lift or carry objects weighing up to 20 pounds. Jobs in this group are required to have close visual acuity to perform activities such as: extended use of computers, preparing and analyzing data and analytics, and other components of a typical office environment. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).

Work Environment:
Jobs in this group are required to function in a fast paced environment with occasional high pressure or emergent and stressful situations. Frequent interaction with a diverse population including team members, providers, patients, insurance companies and other members of the public. Function is subject to inside environmental conditions, with occasional outdoor exposures. Possible exposure to various environments such as: communicable diseases, toxic substances, medicinal preparations and other conditions common to a hospital and medical office environment. May wear Personal Protective Equipment (PPE) such as gloves or a mask when exposed to hospital environment outside of office. Reasonable accommodations can be made to enable people with disabilities to perform the described essential functions. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).