DEPT OF HEALTH SERVICES

Address: 501 N. 24th Street, Phoenix, AZ 85008

Salary: $36,012 

Grade: 14

This position maintains and monitors medical records to ensure accuracy and timeliness of documentation from patient admission to discharge, and reports on compliance with requirements of regulatory entities and hospital policies and procedures. This position responds to requests for medical record information from external entities while maintaining the confidentiality of patient information. The Medical Record Specialist facilitates the completion of medical records by communicating with various clinical staff, including physicians, nurses, social workers, psychologists, nutrition services and rehabilitation therapists. This position assists in the development, maintenance and monitoring of complete and accurate medical records by utilizing chart audit tools. The Medical Record Specialist ensures that all forms on the units are current and available and assists in the integrity of the medical record. This position must demonstrate knowledge of HIPAA privacy regulations as evidenced by appropriate handling of PHI, promoting confidentiality and using discretion when handling patient information. The Medical Record Specialist redacts PHI from health record documents prior to distribution outside of the Hospital. This position enters patient information into the EHR by scanning paper documents or importing electronic files according to department guidelines. Accuracy is essential for scanning and indexing the paper documentation into the EHR. Accordingly, this position examines patient records to ensure that both sides of the document have been scanned, pages are oriented correctly, and that, overall, the quality of the document is acceptable.

-Maintains inpatient and discharged patient health records to ensure accuracy, completeness and timeliness in compliance with regulatory agencies such as the Joint Commission, CMS, and files discharged charts into the terminal digit filing system.

-Completes chart audits of patient records, from admission, throughout hospitalization and upon discharge, according to department guidelines. Medical Records charts may consist of both paper and electronic documentation. Charts are audited for completeness and timeliness of documentation, to ensure compliance with regulatory standards.

-Retrieves documents from the patient units for scanning into the EHR. Examines documents to ensure that patient identification is on both sides of the document. Scans or imports documents into the EHR and examines them to ensure that both sides have been scanned and are oriented correctly. Assists with training of staff in the new EHR.

-Maintains patient health records according to hospital guidelines. Creates and maintains addendum folders according to prescribed format.

-Assists in the verification process of discharge data by auditing discharged patient records for accuracy and completeness of information reported to the Joint Commission.

-Responds to requests for information from external review organizations. Redacts PHI from documents prior to distribution.

-Completes the Master Patient Index search accurately to determine prior admission history. Pulls previous admission record and brings it to the unit for clinical staff review.

-Other duties as assigned as related to the position (typically 5% - 10%)

Knowledge of:
- Medical terminology and anatomy.
- Accepted methods and techniques in maintenance of medical records.
- Laws, rules, and regulations regarding medical records.
- Medical record documentation standards as established by the Joint Commission, CMS standards, and state licensing regulations.
- Hospital rules and regulations relating to documentation requirements in the health record.
- HIPAA requirements for protected health information.
- Personal computer software (i.e. Word, Excel) as well as an electronic health record system.
- Performance Management (PM), and Continuous Quality Improvement (CQI) and Lean methodologies.

Skill In:
- Interpersonal skills to interact with a variety of professional and para-professional staff, the patients, and the public.
- Oral and written communication.
- Detail-oriented.
- Skills in filing complex medical information and documents.
- Audit skills to determine the completeness and accuracy of medical record documentation.
- Computer skills in a variety of software packages applicable to medical records management.
- Time management skills

Ability to:
- Maintain confidentiality.
- Accurately and efficiently file and scan documents.
- Concentrate for long periods of time.
- Use a variety of office equipment, i.e. fax, scanner, copier, computer, printer.
- This position is required to perform work at/attend meetings at alternate locations and/or travel when necessary.
- Support a diverse multi-cultural workforce that reflects the community, promotes equal opportunity at all levels of public employment, and creates an inclusive work environment that enables all individuals to perform to their fullest potential free from discrimination.

Preference will be given to candidates with two years of medical records experience.

-Driver's License.
-State hospital employee must possess a valid level one fingerprint clearance card issued pursuant to A.RS. 41-1758.07 or must apply for a level one clearance fingerprint clearance card within seven working days after beginning employment.
-NOTE: If position is required to drive on state business, the position will require the possession of and ability to drive.

“This position is subject to the vaccination requirements outlined in CMS Interim Final Rule - Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination (published November 5, 2021) (86 FR 61555).”

If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver’s License Requirements.

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

The State of Arizona provides an excellent comprehensive benefits package including:
− Affordable medical and dental insurance plans
− Paid vacation and sick time
− 10 paid holidays per year
− Wellness program and plans
− Life insurance
− Short/long-term disability insurance
− Defined retirement plan
− Award winning Infant at Work program
− Credit union membership
− Transit subsidy
− ADHS Student Assistance Pilot Program

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

To help you build a financially secure future, the State makes monthly contributions to finance your retirement benefit. The State will make a contribution to the ASRS in an amount equal to your contribution. In other words, you and the State will each pay 50% of the total cost of the benefit. New State employees have a 27 week wait period for contributions to begin.

Arizona State Government is an EOE/ADA Reasonable Accommodation Employer. Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by calling (602) 542-1085. Requests should be made as early as possible to allow sufficient time to arrange the accommodation. DHS is an Equal Employment Opportunity Employer. All newly hired employees will be subject to E-Verify Employment Eligibility Verification.