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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00118243 |
Description Activated On: 12/22/2025 8:41:18 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. Technical work assisting in the operations of the Medical Records Department of a State Psychiatric facility. The employee is primarily responsible for maintaining security and confidentiality of all medical records. By adhering to Wernersville State Hospital (WeSH) confidentiality policy and hospital accreditation/certification agency standards to safeguard all medical records against fire, loss, tampering with, or use by unauthorized persons. Organizing and performing technical work of managing paper charts and the Electronic Health Record (EHR). |
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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. Verifies accurate and appropriate coding of patients’ diagnoses on various clinical documentation items including those related to insurance billing. Assists clinicians in choosing the correct diagnosis codes for more specialized or detailed items. Audits charts, documentation, assessments, and other relevant materials in both the paper records on the unit, and EHR system or other locations to access records. Maintains and updates the master patient index card filling system. Codes paper and electronic charts for procedures performed by physicians to include all Podiatrists, Psychiatrists, and licensed Psychologists. This shall be completed for all patients of WeSH having valid insurance or payer, using the physicians Current Procedural Terminology (CPT) coding system, ICD10 (or more current) coding system and the most current version of the Diagnostic Statistical Manual (DSM). Reviews documentation related to billed services and advises provider of essential elements missing from documentation. Updating/aiding in fixing diagnosis in the EHR system. Coordinates with department staff to ensure all services are prepared prior to communication of readiness to bill to the reimbursement office. Billable encounters are reviewed and referred for editing on a regular basis and completed by set intervals each month. Organizes and maintains a tickler file system to track completion of documentation for coding/billing processes. On a monthly basis, generates a discipline and provider specific report for executive level management regarding the monthly Medicare Part B encounters billed. You can leave this in- if this is tied to the green highlight, we can look at a better way to do this. Pulls the NCPDP - Eligibility Verification (E1) request for all patients upon admission or as requested. Updates/maintains all patient financial eligibility (insurance) in the EHR to include Medicare Part A, B, D (prescription insurance), private insurance, medical assistance, and non-billable insurance(s) for all individuals. Sends out reminders to providers about completing patient financial capacity. Tracks, maintains, and enters capacity data. Assists in purging medical records that fall under the criteria laid out by the records retention and disposition schedule, as well as charts from previous hospital closures. Functions as CSP meeting recorder, transcribing meeting notes and returning/routing in draft format in the EHR system. Releases protected health information in compliance with HIPAA and hospitals confidentiality/release of information policy for routine requests. Refers all legal and non-routine requests for protected health information to the Medical Records Director. Sends out protected health information with appropriate disclosure statement and logs each disclosure per facility and DHS protocols. Prints and provides protected health information from the EHR system to assigned administrative investigators as needed for active investigations. Pre-admits/admits patients into the EHR and patient tracking system(s), along with entering patient bed switches, movements, leaves, deaths, and discharges. Updates physician coverage/changes within the EHR System. Enters the legal status of the patient’s current court commitment and open or active legal charges into both EHR and patient tracking systems. Scans/logs court commitment/petition information for addition to the EHR Scans and indexes patients protected health information, photo identification (ID’s), social security cards, birth certificates and insurance cards; if applicable into the EHR system. Completes chart assembly and analyzes the medical record for deficiencies. Flags and sends out staff deficiencies found within the chart no later than a calendar year and/or within 30-days after discharge. Reviews and ‘saves as’ the 24-hour report into the census folder and makes necessary changes to the census. Runs census report in patient tracking and the EHR system to check for errors. Will notify the medical records director if any shall occur. Prepares monthly reports related to census data, discharge, admission, leave, movement, court commitments and other patient data. All work is completed with attention to detail and care to ensure information entered in paper or electronic methods is accurate. Ensures chart entry is in the right records and processed according to established protocols. Handles patient information and PHI to ensure security and maintains HIPAA compliance up to including disposal of PHI. Files, sorts, scans, prints, lifts, bends, pushes, pulls, and transports records and incoming mail to/from designated areas. Contacts proper individuals and/or completes a work order for repair and maintenance of office equipment. Attends mandated trainings and seminars which are applicable to job duties/classification. Assists the medical records director with other duties/designated tasks. Performs other related duties as assigned. |
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. Independent decision making is required within the scope of the position’s daily duties, prioritizing the order of importance. To seek directors’ guidance in unordinary situations/circumstances. |
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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: N/A Licenses, registrations, or certifications: 1. N/A 2. N/A 3. N/A 4. N/A 5. N/A 6. N/A |
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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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