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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00096250 |
Description Activated On: 10/17/2025 11:06:21 AM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. Makes routine clerical decisions regarding typing, report processing, releases PHI in answer to routine requests with a high degree of accuracy and proficiency consistent with current policies and procedures both internal/external to the hospital. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. 1) Reviews all medical records (7-10 calendar days following the initial treatment plan and annual updates) for completeness, timeliness, and accuracy of treatment plan entries and multidisciplinary admission and annual assessments. Records deficiencies on a Data Collection Document form and distributes copies in accordance with departmental procedures. Medical Records are in paper and electronic format. 2) Completes the Diagnostic Recording Form (7-10 days following the initial treatment plan and annual updates), coding all psychiatric and medical diagnoses. 3) Assembles, arranges, files, reviews, and verifies the accuracy and completeness of medical record documents in compliance with the standards of the hospital, the department. and various accrediting agencies. 4) Files all required materials in the active and overflow records, making sure that each page is properly signed and with complete patient identification on each page before filing in accordance with the appropriate chart index. Repairs any torn pages and replaces any worn labels or record binders as necessary. 5) Ensures that charts of patients who are Medicare Part B or MA recipients are labeled accordingly. 6) Codes medical records to complete Medicare Part B encounter billing documents. 7) Files and retrieves patient medical records and maintains them in a neat and orderly fashion. 8) Purges material from the medical records in accordance with the timetable in the approved index for medical record documents. 9) Tracks the discharges on assigned unit. Keeps the Medical Records Director informed of all potential delinquent discharge records. 10) Completes the Medical Record Face Sheet, typing the date of discharge, the diagnoses, and the appropriate diagnostic codes as required by accrediting bodies. 11) Forwards all necessary discharge/treatment information to the appropriate aftercare provider(s) upon the patient’s discharge. 12) Responds to telephone inquiries about patient medical records in accordance with established confidentiality regulations. 13) Files forms in unit charts after they have been processed. 14) Upon discharge or death of a patient, assembles the documentation from the unit and overflow records in accordance with the index. 15) Following discharge, forwards the record to the Central Medical Records Department along with the empty binder and addressograph. 16) Facilitates completion of Medical Assistance forms. Promptly distributes forms to appropriate staff and delivers or forwards completed forms to required destinations. 17) Handles requests for information from third party payers, attorneys, outside treatment facilities, and other agencies in accordance with the hospital’s policy on confidentiality of Protected Health Information. Selects the appropriate material from the record and photocopies same for submission to the authorized requestor. 18) Retrieves Incident Report forms from each unit on a bi-weekly basis in accordance with established hospital procedure. Forwards the reports to the Quality Assurance Risk Management Coordinator. 19) Places patient and professional staff mail in designated mailboxes in patient buildings. 20) Transcribes and edits reports from machine recorded or handwritten material containing medical and psychiatric terminology, such as discharge summaries and assessments, clinic consultations, correspondence and reports to committing judges, attorneys, and referring agencies. Sends letters to families, as well as interoffice memoranda, etc. Proofreads all typewritten material for accuracy. 21) Ensures that the outsourcing transcription service adheres to the 48-hour turnaround time regarding discharge summaries, clinic reports, and court letters. 22) Distributes admission information to the appropriate attending psychiatrist, medical doctor, psychologist, and social work team. Files the commitment papers, and orders on unit chart. 23) May attend court hearings when scheduled in the assigned courtroom area or on the unit. 24) Keeps professional staff, hospital administration and court officials abreast of consumer commitment status. 25) Maintains the following departmental databases: correspondence and census reports. 26) Communicates to Director when office and paper supplies need to be ordered for the Medical Records Department, which includes stationery, paper, and medical records forms. 27) Maintains and monitors office equipment, i.e., personal computer, typewriter, fax machine, photocopier, etc. used in the Medical Records Department and reports issues to Director. 28) Updates the stat medication, incident reporting, and other databases. Updates the admission and discharge spreadsheets. 29) Prepares the CEO report, vacancy report, demographic report, cumulative admission and discharge report, length of stay report, population by county report, patient days report, and bed days report. 30) Completes other duties as assigned by the Director of Medical Records. Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. Makes routine operational decisions regarding the H.I.M. - Medical Record Department such as chart analysis, filing/stamping of record documents, coding (ICD-10-CM), supply requisitions, routine telephone inquiries. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. Makes routine operational decisions regarding the H.I.M.-Medical Record Department such as chart analysis, filing/stamping of record documents, coding (ICD-10-CM), supply requisitions, routine telephone inquiries. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. 5. 6. |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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