• Prepare admission charts/records; assemble charts for new admissions with appropriate forms; label chart with correct patient/physician information and label patient rooms with patient information and physician's name
• Complete the admission documentation; assist physicians with charts; ascertain the expectations of the patient and family regarding the hospital stay
• Confer with the charge nurse on scheduling patient tests and activities
• Adhere to isolation precautions and OSHA blood-borne guidelines, using personal protective equipment as required
• Answer telephone and call lights, take messages and communicate promptly to the appropriate person
• Make hourly rounds to each patient's room to assess any unmet needs
• Process patient discharge orders, notifying the nurse of the orders; copy information on chart to be sent to discharge facility; complete discharge paperwork and assist the family with the discharge process
• Under the direction of the nurse manager, order, receive and store supplies and equipment
• Ability to multi-task and organize and management medical records department.
• Knowledge of ICD-9/CPT coding, abstracting, JCAHO and federal regulations.
• Knowledge of state and federal laws regarding patient confidentiality and release of information.

Required:

Requires two years of recent hospital experience.

Preferred:

• Current certification as a nursing assistant or Associates degree in Health Information Technology and satisfactory completion of a coding course preferred.
• Certification as a RHIT preferred