Medical Records Transcriptionist jobs in San Antonio, TX

Summary:  Responsible for maintaining GMG Electronic Medical Records (EMR) by importing and organizing documents correctly/timely manner.  Receives documents from internal sources, external medical offices/facilities in paper and electronic formats.  Reviews medical records for accuracy and completeness.  Fulfills properly executed record requests.  Maintains HIPAA Compliance and serves as resource to GMG staff.   

Duties:

1. Regularly retrieves paper documents from the Clinical Areas following defined protocols.  Verifies that paper documents are properly labeled to ensure the right patient and right medical record.  Documents any records that have been submitted without valid name, DOB or other identifying information according to established protocols.
2. Scans paper documents into defined software system to prepare for import to EMR.  Imports documents into the patient record correctly:  Right Patient, Right Record, Right Document Designation, Right Date of Service, Right status (signed / unsigned).
3. Organizes and evaluates patient medical records. Reviews medical records for accuracy and completeness.
4. Releases records accurately and in timely manner while maintaining HIPAA compliance, including release of records to patients, referral specialists, QI entities, legal requests, etc. 
5. Reviews subpoenas to ensure records are accurately produced according to request and delivered to appropriate parties within defined time periods. Documents record releases correctly in EMR.
6. Performs other special Medical Record review activities (Home Health Records, Diabetic Shoe Documentation, etc.) as defined.
7. Exercises tact and courtesy when dealing with patients, visitors, physicians, and co-workers.
8. Documents appropriately in GMG computer systems, and other associated systems.
9. Successfully meets production and quality goals.
10. Maintains strictest member and company confidentiality. Ensures member health information is secured each day.
11. Able to work efficiently under pressure.
12. Other duties as assigned.

Education and Experience:  Minimum high school education or equivalent. Previous medical records experience required. Medical terminology helpful. Able to work efficiently under pressure.  Ability to communicate effectively, written and verbal.

Computer Skills: Knowledge of Word Processing software, database software, spreadsheet, and Internet software

Supervisory Responsibilities:  This job has no supervisory responsibilities.

Work Environment:  Depending upon the area assigned, may be 100% clinical setting or office setting in a clinical environment). Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment. 

Physical Demands:  Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. Close vision and ability to adjust focus.
 

The above job description is not intended to be an all-inclusive list of duties and standards of the position.  Incumbents will follow any other instructions, and perform any other related duties, as assigned by their supervisor.  Reasonable accommodations may be made to enable otherwise qualified individuals with disabilities to perform the essential functions of the job.