Tufts Medical Center Operations Specialist in Boston, Massachusetts
Department: Health Information Management
Schedule: Full-Time Regular
Shift: Evening shift
Associate's degree is preferred
Under general supervision, this position ensures that patient charts are retrieved, assembled in paper order and scanned within 48 hours post discharge.
Retrieves records from each Nursing Unit or patient care area for all discharged patients and assembles the various clinical documents according to the approved standard chart order for each record type, including all electronic medical records documentation, test results, pathology reports ,CPOE order sets, EHR Orders and NUR documentation are printed, verified and added to create a complete paper record. Records must be processed timely to ensure they are available for coding, patient care if re-admitted, and various requests for information.
Thoroughly analyzes assembled records for documentation deficiencies by Physicians and clinicians, including completeness of the clinical documentation, dates, times and signatures following the strict CMS regulatory, Joint Commission accrediting agency standards and Federal & State legal guidelines. Accuracy is of utmost importance, as the Analyzed deficiencies are the basis of reporting delinquent records by Physician to the Medical Staff Executive Committee and ultimately used for Suspension of Physician privileges.
Responsible to perform the highest level of QA to ensure that the medical record documentation represents the complete legal medical record for the Hospital for use by coding, auditors, legal proceedings, continuity of patient care, Physician Suspension process and patient requests.
Assists with the processing of confidential requests for the authorized release of patient medical information & medical records, physician requests.
Ensures accuracy with the processing and filing of the Advanced Directives and processing the Psychiatric Authorizations to Release to PCP to meet the Mass Health Pay for Performance Measures.
Responsible for responding to various types of requests for medical record information, filing, maintenance, retrieval, and delivery of medical records and related documentation to requestor(s)of all medical records requested according to established HIM Department policy and procedure, accuracy and productivity expectations.
Responsible for verifying and filing various documentation into patient medical records according to HIM Department policy and procedure.
Maintains health record tracking system for all records and medical record information requested, distributed from and received by the HIM Department.
Verifies, corrects and maintains patient folders and unit numbers by referring duplicate numbers, incomplete identification, volume discrepancies or similar issues to the HIM Operations Manager.
Adheres to HIM Department and hospital-wide quality assurance standards.
Fosters respect for patient privacy and confidentiality by maintaining and upholding the highest level of confidentiality in all phases of the work.
Follows hospital and department policies and procedures to contribute to the safety, efficiency and effectiveness of the Health Information Management Department and hospital.
Health Information Management experience preferred
Trains new personnel on retrieving inpatient charts on t he nursing units and assembling medical records.
Performs other similar job related duties as required or directed.
Attention to details.
Ability to utilize computer system to look up basic information. Previous computer experience preferred.
Level of knowledge generally obtained via completion of high school.
Three months of general office experience