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Medical Records ClerkCompany Decypher Technologies
Location Fort Sam Houston, TX
Update 6 Day ago
Decypher Technologies is a leading integrator of professional, technology, and management solutions and services. We provide our services globally to Federal, Commercial, Local and State clients. Our employees are our most valuable asset and play an integral role in the success of Decypher and our clients. Working at Decypher is not a job, but a career where your talent and energy is respected and you can personally make a difference. Decypher invites you to join our professional team. Decypher is an equal opportunity/affirmative action employer committed to diversifying its workforce (M/F/D/V).
Decypher Technologies is looking for full time Medical Records Technician for the Department of Emergency Medicine at the San Antonio Military Medical Center (SAMMC), Brooke Army Medical Center (BAMC) located at JBSA - Forth Sam Houston, Texas.
The responsibilities of the position include:
Perform established administrative duties related to admission process: Receive and interview patients and/or sponsors, or other persons having knowledge of or accompanying the patient in the Emergency Department (ED). Schedule related appointments and follow up to ensure patients kept scheduled appointments. Upon notification of an admission, obtain all pertinent demographic data required by law and regulation and enter information onto DA Form 2985, Admission and Coding Information. Inform patient of the availability of the Patient Trust Fund for securing valuables. Answer questions regarding admission policy, patient transfers, and medical specialty requirements.
Ensure patient ED record is closed out in the Composite Health Care System (CHCS) prior to admission.
Work closely with ED, and Nursing Staff to arrange routine transfers of patients from the ED to other healthcare facilities: Locate an accepting physician and hospital. Obtain administrative approval from the accepting facility and physician. Complete required portions of the BAMC Form 983, Memorandum of Transfer prior to contacting the Patient Administration Division (PAD) for patient transportation arrangements. Ensure consults (Electrocardiogram (EKG) and Continuations Sheets) are attached to the ER copy.
Collect Third Party Insurance data from all nonactive duty uniformed service beneficiaries and civilian emergency/Institute of Surgical Research patients visiting the Emergency Department (ED). Initiate and complete as much as possible, DO Form 2569. Conduct individual followup interviews with those individuals to ensure accurate complete data. Make copies of Medicare, Veterans Administration, or other health insurance cards when available.
Verify and input into CHCS all other health insurance information. Make copies of all new, modified or annual DD2569s and send one to the PAD for filing in the patients record and one to Uniform Business
Counsels/Briefs all eligible TRICARE beneficiaries not enrolled, on the benefits, capabilities and limitations of TRICARE at checkin. Direct all individuals to the TRICARE office to complete enrollment process if interested or eligible. Discuss with all eligible beneficiaries not enrolled to BAMC on the benefits of enrolling to TRICARE Prime at BAMC
Receive all incoming telephone calls and visitors. Use pager system to page medical staff. Provide information as to the procedure to follow for registration, location of clinics, operating hours, etc
Verify and update all patient demographics data files via computer software provided such as: CHCS, Defense Enrollment Eligibility Reporting System (DEERS), and the Ambulatory Data Module (ADM). Request clarification of data from patient for completeness and obtain additional information as required. Ensure registration data is accurate and complete. Correct all CHCS registration problems when requested by supporting services, (xray, lab, etc.)
Verify patient eligibility upon admission using the DEERS, and by checking for valid identification. Make appropriate followup checks on patients found to be ineligible to include confiscating military identification and/or referral to the ER Supervisor. Ensure military orders and letters of authorization have appropriate dates and signatures authorizing treatment within the facility. Exercise tact and courtesy in all dealings with patients, families, and staff members at all times
Ensure full insurance data, demographics, and CHCS registration data is complete on trauma patients who are treated and released from the ER. Initiate patient record for treatment (SF558).
Obtain registration information on patients arriving via ambulance as soon as they arrive, information may be obtained directly from patient while in trauma room, family members, friends or search in various computer databases. Forward a copy of the ambulance run sheet or other paperwork to PAD when available.
Perform administrative oversight for end of day closeout logs and reports. Assist ED clerks when necessary in retrieving and ordering lab and x ray reports. Prepare and attach slips and labels to a variety of specimens collected and prepared by the medical staff; gather and record laboratory results using data retrieval computer system when requested by care providers. Attach lab and x ray results to patient charts and notify doctors that the results are available. Contact other departments for a variety of support (e.g., medical records, portable xrays, etc.)
Oversee clerk registration process. Assist ED clerks when necessary in interviewing patients for eligibility for care and to obtain necessary demographic and billing information to register patients. Register new patients into CHCS in accordance with BAMC guidelines and assign appropriate Patient Category (PATCAT). Initiate patient record for treatment (SF558). Immediately contact triage nurse of patients presenting with any life threatening conditions.
Completes all initial and annual training requirements according to hospital policy.
Greets and receives visitors and provides assistance as appropriate. Receives incoming telephone calls, takes messages and routes or delivers it to appropriate office staff member. Utilizes and manages communication pager or intercom system to page office staff members.
Complies, with HIPAA, Joint Commission, and other appropriate governing directives regarding the management and release of medical information.
Assists with faxing, filing, copying, scanning, collating, and binding of materials. Prints file, mailing, and specimen identification labels. Generates and formats reports, forms and listings by sorting, selecting and merging documents. Types a variety of materials, reports, and/or reports. Insures usage of correct spelling, format, and grammar. Copies and mails out documents. Collects, sorts, and delivers incoming and/or outgoing correspondence. 11.5.4 Maintains current oncall listings, alert rosters, and directories on designated offices and agencies. 11.5.5 Stock Emergency Room (ER) form supplies (by copying forms or checking the stockroom).
Perform End of Day Processing in the Composite Health Care System (CHCS) for Patients who present themselves for medical care.
Copy medical records as requested.
Retrieve both inpatient and outpatient medical records.
Order and followup CTs, MRIs, Nuclear Medicine scans, labs and xray orders. Attach lab/x ray results to patient charts and notify doctor that results are done.
File Emergency Medical Service (EMS) run sheets daily.
Outpatient charts: retrieve records/charts from the out box in the Team Center.
Make copies of all documentation for the ER files (if copies are not attached). Place original documents at the front desk for return to medical records, and place copies in the appropriate file box for filing.
Log information into CHCS ER Module ensuring the following patient data is entered listing the Provider Name, Time Seen, Time Left, Disposition Condition of patient on arrival (non urgent/urgent/emergent), Method of Transport and Pertinent Patient Instructions
Ensures consults, Electrocardiogram (EKG), and continuation sheets, located in the bottom box are attached to the ED copy.
Initiate and coordinate a Memorandum of Transfer for ER to other facilities.
Log Patients in to the ER, print ER chart, labels, and medication reconciliation form.
Put together Patients charts, put them in a folder, and place them in the rack outside the triage room for the triage nurses.
Make sure that if a Patient comes in with a RED FLAG concern (chest pain, active bleeding, weakness, etc.) the chart is marked appropriately with a red star, places in a red folder, and put in the rack for the triage nurses.
Register Patients in the Composite Health Care System (CHCS).
Have Patients fill out Third Party Insurance Information paper work if needed.
Update demographics and Insurance Information in the CHCS system when needed.
When system goes down keep a Patient log with Patient name, address, and phone number, date of birth, age, sponsors SSN, and chief complaint. Fill out blank down time charts with all pertinent information from Patient Log.
Make labels on the EZ ID down time computer for chart and Lab/Radiology order forms.
Initiating DD form 2341 Report of Animal Bite when a Patient that requires it checks in, and making sure that the doctor fills form out when patient is released. When closing and breaking down chart that it gets faxed to appropriate clinics, and placing a copy at front desk for VET TECH to pick up.
Completes all initial and annual training requirements according to hospital policy.
Required Skills include:
Performing assigned duties in an efficient, reliable, and professional manner.
Speak, read, and comprehend English to the extent that candidate can read and understand printed regulations, detailed written orders, operating procedures, training instructions and materials and perform the duties assigned.
Possesses core competencies that include basic customer service skills and handling of routine and complex inquiries via telephone and email.
Upholds the highest standards of integrity, honesty, openness and professionalism.
Computer literate with a variety of software applications, including digital imaging and document management; word processing; and spreadsheet program applications.
Basic knowledge of medical terminology
Knowledge of medical records procedures, regulations, and principals to carry out a variety of medical records functions.
Knowledge of legal and regulatory requirements of medical records.
Skilled in effective oral and written communication sufficient to prepare reports, effectively interact with hospital personnel and professional organizations, and make presentation of findings, etc.
Preferred Skills include:
Familiarity with CHCS, AHLTA, and Essentris
2+ years experience in medical records processing