Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Health Information Management

Job Family

Clerical

Work Shift

Evenings (United States of America)

Summary

Responsible for assuring patient records and loose documentation are prepared and scanned for processing into the electronic document management system with the highest level of quality possible. Responsible for identifying and correcting errors via Verifier module, to provide accurate patient encounter and document type. Responsible for performing quality control functions on scanned charts.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Verify receipt of all inpatient and/or outpatient discharged records utilizing the reconciliation report

• Prepare medical record documents for scanning according to procedure

• Scan documents within the established productivity standards

• Validate the accuracy and completeness of medical records in the electronic medical record system

• Confirm the imaged documents are indexed to the correct patient, encounter and document type

• Confirm the accuracy of the imaged document, identifying items requiring correction and corrective action as needed

• Ensure the integrity of the legal medical records and strictly uphold patient confidentiality

• Release patient information consistent with established guidelines

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• High school graduate or equivalent required

Work Experience: 

• 2 years of Health Information Management experience required

• Scanning experience preferred

Knowledge, Skills, and Abilities Required: 

• Proficiency in reading, writing, and speaking the English language

• Ability to type 40-45 wpm accurately

• Sufficient keyboard familiarity

• Intermediate knowledge in the use of computers in a Windows environment

• Knowledge of general medical record format and content

• Basic understanding of medical terminology

• Knowledge of Joint Commission and other regulatory agency chart documentation requirements

• Organizational skills with the ability to manage multiple priorities and make good independent decisions

• Attention to detail and quality to include strong recall and recognition skills

• Ability to work in a team environment as well as self-directed and resourceful in order to work alone when necessary

• Ability to work under pressure with ongoing time constraints

• Ability to provide excellent customer service to enhance patient care delivery by assuring timely and accurate access to medical records

• Excellent written and oral communication skills

• Positive attitude and enthusiasm

Physical Requirements: 

• Professional appearance

• Extended periods of sitting

• Some instances of reaching, bending, stooping, pushing, and pulling all requiring use of proper body mechanics

• Ability to work productively in a high volume, high stress work environment

• Visual acuity for reading and processing charts/information

• Dexterity of upper extremities and fingers

• Mental dexterity for accurately sorting medical record documents

• Light to moderate lifting of up to 25 pounds of boxes containing medical record documents

Required Licenses and Certifications

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity