GENERAL DESCRIPTION:

The Medical Records Data Processor I (DPI), under the direction of the Medical Records Supervisor, is responsible to comply and enforce the organization and department policies and procedures, the National PACE Association (NPA) standards, Center for Medicare & Medicaid Services (CMS) and the Electronic Medical Record (EMR) guidelines. Responsible for data entry, audits and corrections for assigned census panel. Scans, audits and uploads all relevant documents into the EMR systems, assists with the Interval and Assessment and the Service Utilization processes. Prepares and audits all external requested medical records in addition to the admission and monthly medical records to Nursing Home and Assisted Living facilities. Serves as the back-up for the Electronic Progress Note processes. Performs various clerical / secretarial functions, projects and reasonable duties as assigned.

RESPONSIBILITIES:

A. ELECTRONIC MEDICAL RECORD PROGRAMS AND PURGE FILE DOCUMENTATION:

• Follows the EMR and scan program guidelines
• Completes the paper and electronic data scan and / or data upload and audit processes
• Completes data collection /data entry, audits and corrections in the EMR for the assigned census panel (example: PACE logic demographic information, Prime suite document upload file name, etc.)
• Prepares the purge and closed files for the assigned census panel; to be sent to purge / closed file room
• Assists the Data Processor II with the preliminary transfer process, monthly and / or quarterly data collection and its corresponding reports
• In the absence of a Progress Note team member, serves as the back-up to the Electronic Progress Note processes

B. SERVICE UTILIZATION REPORT:

• Collects and tracks the data for the service utilization report prior to submitting to the data processor II for the final data entry and report processes
• The DP-1 verifies hospitalization and emergency room admission and discharge dates by contacting facility staff

C. INTERVAL AND ASSESSMENT (I/A):

• Assists the Data Processor II with the Interval Assessment missing evaluation audit

D. MEDICAL RECORD REQUEST, SUBMISSION AND AUDIT PROCESSES:

• Prepares and audits the medical record packets for participant admissions and monthly medical records for nursing home / assisted living facilities and maintains the requested medical record tracking binder
• Request, track and complete the medical record request processes for the participant hospital stays and emergency visits
• Request, track and complete the medical record request processes for visitors
• Request, track and complete the medical record request processes for the electronic progress note
• Serves as the back-up for the mail-out process
• Conduct the annual audit for the medical power of attorney, advance directives, legal guardianship documents in binder against the EMR
• Conduct the annual audit for the full code, advance directives and out of hospital DNR code status documents in the binder against the EMR

E. MEETINGS:

• In the absence of the Data Processor II attends and obtains the daily morning meeting minutes and center information
• Attends the department staff meeting, training and in-services (for missed meetings, staff is responsible to meet with the supervisor to obtain information)

F. ADDITIONAL AND DUTIES AS ASSIGNED:

• Prepares the monthly supply request for center operation needs
• Assists with the Nurse Wise process
• Performs various projects and clerical duties as assigned

Required Skills

1. Extensive medical terminology knowledge

2. Strong typing skills, fast and accurate

3. Strong data entry skills

4. Strong computer skills to include knowledge of Microsoft Office applications; Word, Excel, Outlook, etc.

5. Ability to follow directions, instructions, policies and procedures in any format, including verbal and written

6. Good communication and telephone skills, courteous and professional

7. Ability to work independently

8. Ability to maintain an effective working relationship with staff at all levels

Required Experience

1. High school diploma or GED equivalent required

2. Certified from an accredited technical/trade school in the medical field required

3. Two (2) years of work experience in the medical field preferred

4. Electronic health records program experience preferred

5. Document scanning experience preferred

1. Extensive medical terminology knowledge

2. Strong typing skills, fast and accurate

3. Strong data entry skills

4. Strong computer skills to include knowledge of Microsoft Office applications; Word, Excel, Outlook, etc.

5. Ability to follow directions, instructions, policies and procedures in any format, including verbal and written

6. Good communication and telephone skills, courteous and professional

7. Ability to work independently

8. Ability to maintain an effective working relationship with staff at all levels