Eastern Maine Healthcare System CLINICAL HEALTH INFO SERV TECH in Portland, Maine
Under the supervision of Health Information Management (HIM), and guidance of the Mercy Medical Group (MMG) Leadership team, the Clinical HIM Tech is primarily responsible for chart abstraction. Chart abstraction must be performed in accordance with the approved data abstraction list and within the timeframe specified.
Incumbent will be a team player and in addition to the chart abstraction process will participate in the transfer of current and historical patient information from a paper chart into an electronic record (EMR). Performs data entry into the EMR system using a scanner. May perform chart prepping, scanning, quality control and indexing of medical record documents.
Maintains daily workflow, ensuring that records are processed in a timely and efficient manner and are of the highest possible quality for end use viewing. Maintains confidentiality in all aspects of the job. Abstracts all prepped documents into the electronic system on a daily basis in order to ensure quality data is available to end users within the timeframe established in department guidelines. Researches any identified discrepancies in medical record data and corrects the record according to guidelines. Answers department telephone in a timely and courteous manner. Performs Quality Assurance per department guidelines
The incumbent is responsible for participation in and completion of all patient safety initiatives appropriate to the position. The incumbent may have access to highly confidential patient, employee and/or Mercy proprietary information, and must handle & protect the information in accordance with hospital & system policies, HIPAA requirements and the highest level of ethical standards. The incumbent is responsible for reporting all security events, potential events, or other security risks to the organization. The incumbent is responsible for participation in and completion of all patient safety initiatives appropriate to the position, and conducts all job responsibilities according to the Mission and Values of Mercy Hospital
Certification as a Medical Assistant or State of Maine License as a Licensed Practical Nurse or Certified Nursing Assistant. Graduate of an approved medical assisting program; or education enabling State of Maine licensure as a Licensed Practical Nurse or Certified Nursing Assistant. One year experience in a hospital or physician practice environment is preferred. Experience in practice or hospital EMR/HIM computer software experience to include scanning and indexing is preferred. Must have good interpersonal skills as the incumbent interacts with physicians, other departments, staff, and individuals outside the department. Must be able to operate independently in completing all tasks with minimal guidance from the Supervisor and/or Lead. Basic clinical skills necessary in order to accurately abstract clinical information and identify missing and/or incorrect clinical information from patient charts and to contact appropriate sources to complete records is required. Must be highly accountable for accuracy, quality, and timeliness of work. Incumbent's performance impacts the ability of the department to provide appropriate clinical care to patients. The majority of the responsibilities of this position impact the integrity of the Electronic Legal Record and the Electronic Medical Record. Strong clinical skills and ability with computers, keyboards, mouse work, and scanners. Ability to work independently and show a preference for routine detailed and organized work.