Medical records Specialist - Yuma, United States - State of Arizona

Description

DEPARTMENT OF VETERANS' SERVICES
For Veterans and those who care for them.


MEDICAL RECORDS SPECIALIST

Job Location:

Address:
Arizona State Veterans' Home - Yuma

6051 East 34th Street

Yuma, Arizona 85365


Posting Details:

Salary:
Up to $17.05

Grade: 14


Closing Date:
May 26, 2024


Job Summary:
Are you detail oriented? Do you have experience in Medical Records Management? The Arizona State Veterans' Home in Yuma is looking for you

The Arizona State Veterans' Home-Yuma is actively seeking a Medical Records Specialist to manage and maintain comprehensive medical records in compliance with state, federal, and VA regulations.

This role is crucial for ensuring that our medical records systems function seamlessly and support delivering high-quality care to our veterans.

If you possess a strong attention to detail and a commitment to maintaining the integrity and confidentiality of medical information, this position offers a rewarding opportunity to contribute significantly to our healthcare services.

As a Medical Records Specialist, you will be responsible for various tasks, including auditing medical records, assigning diagnostic codes for reimbursement purposes, and managing electronic and paper records systems.

You will ensure that records are accurate, systematically organized, and strictly confidential. This role also involves scheduling appointments, arranging transportation, and responding efficiently to requests for medical records.


Your Impact:

• Record Maintenance and Compliance: Maintain records that adhere to all regulatory standards and facility policies, ensuring records are complete, accurate, and confidential.
• Auditing and Coding: Conduct regular audits to ensure completeness and accuracy of records and assign ICD-10 diagnostic codes in the electronic system for reimbursement purposes.
• Appointment and

Transportation Coordination:
Schedule veteran/member appointments and coordinate necessary transportation and escorts, enhancing the accessibility of healthcare services.

• Data Management: Manage daily inputs and updates in the electronic medical records system, ensuring all information is current and correct.
• Regulatory Adherence: Respond to medical records requests in compliance with HIPAA and other relevant laws, maintaining the highest privacy and security standards.

Why Join Us?

• Impactful Work: Your role directly supports the health and well-being of veterans by ensuring the integrity and accessibility of their medical records.
• Professional Development: Engage in continuous learning and application of the Arizona Management System (AMS) to improve work and processes.
• Comprehensive

Benefits:
Participate in the Arizona State Retirement System (ASRS) with enrollment eligibility after 27 weeks of employment.


Job Duties:
As a Medical Records Specialist at the Arizona State Veterans Home - Yuma, you will:

• Within 24 hours of admission, ensure that resident's face sheet is complete and accurately reflecting PHI contacts, independent travel privileges, motorized wheelchair use, alerts & escort communications.
• Research hospital or transfer paperwork as necessary & add missing information to the face sheet electronic record, including but not limited to diagnosis (ICD 10) codes, allergies, code status, Living Will & Power of Attorney, &contact information such as physician, hospice, pharmacy, radiology, laboratory provider.
• Ensure that Pre-admission Screening and Resident Review (PASRR) is included with transfer paperwork. May transcribe orders from hospital/transferring facility into electronic record for verification by Nursing.
• Within 72 hours of admission, audit electronic records to ensure: all observations are completed, consents are signed; medications reconciliation is complete; initial care plans are complete; orders are complete with diagnosis, correct route, etc.; all psychotropic medications have behaviors with monitors & side effects orders; psychotropic medications have signed dated consents for each with classification of each; AIMS is completed; additional ICD 10 diagnosis codes are added to medications as needed.
• Add Pre-hospital Medical Care Directive data to face sheet after assuring order for code status matches signed directive.
• Audit records for each admission and return at 7, 14, & 21 days to assure each interdisciplinary department has completed all observations with accuracy & closed them.
• Audit records at 21 days to ensure completion of full MDS & completion of all necessary care plans; audit records on an ongoing basis to ensure progress notes from clinic consult visits are received in a timely manner & to ensure accurate order entry including category & compliance with regulations, policies & procedures.
• Check for event & observation accuracy & completion.
• Notify appropriate members of inter-disciplinary team regarding incomplete documentation & unverified or unsigned orders; collect documentation from unit box to fax/scan into the EMR & assign to individual resident Electronic Medical Record, including but not limited to labs, x-rays, consult notes, consents, hospital transfer records, etc.
• Audit Medicare Certification/Recertification for timeliness and completeness.
• Provide appointment reminders to residents 3-7 business days prior to appointment.
• For all discharges, assure all signed documentation upon discharge are scanned & uploaded into Electronic Medical Record; complete all discharge tasks.
• Respond to requests for medical records, maintaining compliance with state and federal HIPAA laws.
• Ensure all request are complete & accurate prior to release of documents.
• Print all documents requested.
• If subpoena for records is received, contact Office of Attorney General for their review & direction prior to release; fax/mail to requesting party per policy & HIPAA regulations.
• Conduct quarterly/annual audits of observations, events, orders, preventative health and care plans; conduct a variety of ongoing audits, including but not limited to lab & radiology orders/reports, physician & nursing orders for accuracy of category, flow sheet & correct diagnosis, monitors & consents, resident weight & height.
• Update physician visits in EMR. Updates face sheet as necessary.
• Schedule resident appointments, diagnostic testing, laboratory testing, dialysis, etc.; schedule transportation to/from appointment both outside & to VAMC; contact insurance providers for authorization for appointments & transport.
• Initiate lab & x-ray requisitions based on orders & insurance requirements.
• Initiate request & track profess of consultation orders by gathering required documents, faxing, emailing, & communicating with clinicians to obtain specialty appointments.
• Maintain unit calendar with laboratory schedules, clinic appointments including dialysis & transportation arrangements.

Run facility activity report daily to capture consult requests, lab & radiology orders.

• Fill out requisitions for consults, labs & radiology requests as needed. Attend & participate in a variety of meetings & in-service training.
• Perform bi-annual in-service training on HIPAA for all staff meetings

Knowledge, Skills & Abilities (KSAs):

Knowledge of:

• Health care
• Medical terminology
• Regulatory standards
• Medical office practices
• Medical records maintenance and security paper and electronic
• ICD10 coding and indexing
• HIPAA rules and regulations
• Security rules and regulations
• Record retention and disposal

Skills in:

• Verbal and written communication skills
• Customer service skills
• Auditing a medical record
• Analytical data
• Problem solving
• Data entry

Ability to:

• Transcribe doctors' orders
• Prioritize multiple tasks
• Maintain confidentiality
• Handle multi-line phone
• Use office equipment
• Learn and implement the concepts and tools of the Arizona Management System (AMS)

Selective Preference(s):
Medical records experience in a skilled long term care facility


Pre-Employment Requirements:

• Current Negative TB skin test (Mantoux skin test) within the last twelve months or a written statement from a physician, physician's assistant or a registered nurse practitioner indicating freedom from Tuberculosis, if in the past has had a positive skin test or Tuberculosis
• Must be able to obtain and retain a fingerprint clearance card issued by the Arizona Department of Public Safety

All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).


Benefits:
The Arizona Department of Veterans' Services offers a comprehensive benefits package to include:

• Sick leave
• Vacation with 10 paid holidays per year
• Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child (pilot program).
• Health and dental insurance
• Retirement plan
• Life insurance and long-term disability insurance
• Referral Incentives available for qualifying positions

Learn more about the Paid Parental Leave pilot program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page


Retirement:

• Positions in this classification participate in the Arizona State Retirement System (ASRS)
• Please note, enrollment eligibility will become effective after 27 weeks of employment

Contact Us:
If you have any questions please feel free to contact Human Resources at and for assistance. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.