This position is responsible for various duties relating to obtaining, completing and storing documents and information required for the patient’s Home Health medical record. Many of these duties have time constraints so that documents are available for review by clinicians during the first home visit. This position requires adherence to established policies and procedures to protect patient confidentiality.
Major Position Responsibilities:
Obtains and processes physician orders for entry into the medical record in a timely manner according to state and federal regulations. This includes verification of data elements required and verification of correct physician signature on order.
Prepares list of patient’s current medications for review and verification by nurse at first home visit. Responsible for subsequent mailing of medication list to patient once verified by clinician.
Prepares various system generated reports for auditing purposes to assure that patient ‘s medical record is in compliance with documentation requirements as dictated by state and federal regulations.
- May perform authorizations and eligibility verifications.
- Locates, retrieves, provides, and files medical records as required. This includes submission and retrieval of charts located in off-site storage when needed.
- Enters patient admission demographics and discharge data into the patient’s medical record.
- Responsible to track and assure that a valid Notice of Medicare Non-Coverage (NOMNC) form is obtained for every Medicare/Senior HMO patient according to specific requirements for each payer.
- Organizes and files medical record documents using established systems. Prepares and scans all documents into the patient’s medical record in a timely manner according to department policy. Enters required patient identification information on wound care photos prior to scanning.
- Receives, routes, copies, faxes, and subpoenas for request of patient information, addressing necessary information upon receipt, and ensuring documentation is recorded and logged. Ensures compliance with patient privacy.
- Works closely with both agency clinicians and physicians to resolve issues relating to obtaining accurate and timely documentation. Keeps management informed of any concerns related to this process.
- Follows policies and procedures to contribute to the efficiency of the department concerning patient confidentiality and record location.
- Performs other related duties or projects as requested by department management.
Safety and Infection Control Responsibilities
- Responsible to maintain a safe and clean work environment, including unit based specific safety and infection control requirements.
Qualifications: ESSENTIAL COMPETENCIES, KNOWLEDGE, & EXPERIENCE
- Two years experience in a medical office and/or completion of Medical Assistant/Administrative coursework, required.
- Intermediate computer skills; Satisfactory keyboarding speed.
- Excellent analytical, communication and clerical skills, required.
- Ability to concentrate and perform multiple job functions under limited time constraints with quality results, required.
- Knowledge of medical terminology, preferred.
- Business machine skills - including phone, fax, and copiers, required.
- Experience with medical records processing preferred.
- High School Diploma/GED or equivalent work experience, required.
Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work.