Sr. Medical Records Clerk

GENERAL SUMMARY OF POSITION:

Under the direction of the Administrative Coordinator, this position performs a variety of confidential and complex tasks related to medical record chart reviews.

MAJOR RESPONSIBILITIES:

• Provide quantitative reviews of UMASS Adolescent Units I and II medical records according to Worcester Recovery Center and Hospital utilization management plan and quality management priorities.
• Perform audits in MHIS computer system (electronic medical record) and on paper medical records to review the completion of admissions, assessments, periodic reviews, discharges, transfers according to hospital/unit procedures and MHIS workflow.
• Identify and record medical record deficiencies by routinely entering deficiencies into UM/QM/MR database.
• Through the Reason for Referral (RFR) process provide education to physicians and patient care staff regarding utilization and quality matters as they are identified.
• Print out RFR notifications and distribute to the appropriate individual practitioners for follow-up.
• Conduct a follow-up review of RFR responses to ensure practice improvements as a result of the notifications.
• Provide reports on outstanding deficiencies to designated supervisors and department heads.
• Maintain a high level of confidentiality and ensure that each unit is in compliance with HIPAA.
• Patient health information will be communicated/documented according to DMH and Worcester Recovery Center and Hospital procedures including documenting and reading MHIS medical records to ensure patient health information is current and accurate.
• Compile RFR reports monthly and provide findings to unit leadership and the UM/QM/MHIS Committee, identifying and issues, trends, and/or patterns.
• Prepare payroll as alternate to administrative assistant, as needed.
• Perform other job related duties as required or assigned.

REQUIRED QUALIFICATIONS:

• Associate’s degree in Business or related field or equivalent.
• 3 years of relevant work experience. 

WORKING DEMANDS: 

• Sits at desk for extended periods of time
• Stands and walks for periods of time
• Carries medical records
• Plans own daily work, activities and priorities.  Must be able to prioritize projects within an independent environment, based on the needs of the program

SUPERVISION RECEIVED:

Receives supervision from the Administrative Coordinator

SUPERVISION EXERCISED:

None

ENVIRONMENTAL WORKING CONDITIONS:

Based in an off-site, secure, adolescent psychiatric unit, may interact with patients.  Usual working environment found in office settings.