Electronic Health Record Specialist

San Antonio, TX, United States

Job Details

Job Location

Vighter Corporate Office - San Antonio, TX

Position Type

Full Time

Education Level

Associate's Degree

Job Category

Entry Level

Description

Position Description: Responsible for ensuring all patient medical record data is secure, complete, accurate, and accessible in the CBP Electronic Medical Record system (EMR) and Medication Application

Our Company Promise

We are committed to providing our Employees a stable work environment with equal opportunity for learning and personal growth. Vighters Mission is to provide efficient, fast, high quality healthcare staffing to our clients.

Our Cultures key elements are crucial to the effectiveness of our employees in accomplishing our mission. The key elements include:

Dependability

Integrity

Personability

Transparency

Responsiveness

Creating and cultivating this Culture within the organization is our commitment to our employees. Above all, Vighter employees will be provided the same concern, respect, and caring attitude that they are expected to share externally with every Vighter Client and Customer.

Vighter LLC is recruiting for a Electronic Health Record Specialist. Under the direction of the Patient Safety Risk Manager or in his/her absence the Patient Safety Quality Management Director and in collaboration with the Office of the Chief Medical Officer (OCMO) of U.S. Customs and Border Protection (CBP), the electronic health record specialist works in accordance with the polices and protocols listed in the Statement of Work (SOW) and Department of Homeland Security (DHS) directives for the maintenance of medical records of the delivery of healthcare services to persons in custody.

Contracted medical staff will work alongside uniformed Customs and Border Protection (CBP) Agents/Officers in secured federal facilities along the southwest border of the United States. These secured federal facilities are staffed and monitored by CBP personnel and/or contracted security staff 24 hours a day, 7 days a week to assure a safe working environment to include the co-located medical unit. Contracted medical staff work together with CBP personnel to provide health care services for persons of all ages, to include infants, children, adults, and pregnant females.

Mission:

CBPs Office of the Chief Medical Officer (OCMO) employs a trauma informed care model to provide frontline medical care for persons in CBP custody in accordance with Enhanced Medical Support Efforts CBP Directive (2210-004). This model provides a team of medical professionals comprised of physicians, advanced practice providers (e.g., physicians assistants, nurse practitioners) and support staff (e.g., Licensed Practical/Vocational Nurses, Paramedics, EMTs, Certified Medical/Nursing Assistants). These contracted medical teams provide basic assessment and medical treatment for persons in CBP custody to include emergency care as needed.

Basic Requirements and Licensure/Certification Candidates must be currently certified as an electronic medical records technician, healthcare information specialist, medical records technician, or the equivalent. Certification must be maintained current, and any required education, trainings, continued learning to maintain certification must be completed within the required timeline for completion by the certifying authority. A temporary certificate will not be accepted. Candidate must not have had any professional licensure or certification withheld, suspended, revoked, or denied, and the candidate must not have surrendered or allowed a professional license or certification to have expired or lapsed because of an investigation or disciplinary action.

Candidate must not have been convicted of, pled guilty to, pled nolo contender to, or received probation before judgement for any crime other than a minor traffic violation, the record of which has not been expunged.

Bilingual in English and Spanish encouraged, but not required.

Experience One year of qualifying experience as a medical records technician, medical records clerk, unit secretary, healthcare information specialist, or the equivalent in a hospital, outpatient clinic, nursing home, correctional or detention setting, or other supervised medical, nursing, or patient care facility that provided direct patient care.

Knowledge or medical terminology is required.

Applicant must possess knowledge, ability, and high level of proficiency in the use of Microsoft Office programs, to include Word, Excel, Outlook, and SharePoint.

Education/Training Successful completion of a program in medical records management or the equivalent in an accredited community college, junior college, college or university, or online learning center.

Certification or degree issuing program must be accredited by an entity recognized by the U.S. Department of Education.

Duties and Responsibilities Initiates and maintains compliance with DHS and CBP policies and any overriding accreditation standards that may apply.

Works within licensure/certification.

Maintains compliance with standard operating procedures and protocols.

Maintains patient confidentiality and privacy of medical records.

Performs record keeping functions in accordance with program policies and the system of records management.

Ability to use the electronic medical record and must maintain an active status for use and complete all required trainings.

Utilizes the electronic medical records system for all documentation, and all duties related to patient care or the management of medical records, to include scanning of any paper patient care records or documents.

Maintains non-involvement in the security aspect of custody.

Attends general staff meetings and participates with medical quality management initiatives and reviews as applicable.

Assures a safe and clean working environment.

Completes all annual training as directed.

May be required to travel.

May be required to serve at various medical units within sector/region.

Responsible for ensuring all patient medical record data is secure, complete, accurate, and accessible in the CBP Electronic Medical Record system (EMR) and Medication Application, to include but not limited to:

a. Health Intake Interview

b. Medical Assessments

c. Medical Encounters

d. Enhanced Medical Monitoring Information

e. Medication prescription copies, Medication Administration Records

f. Off-site Referral and Hospital Records

g. Local and State Infectious Disease Reporting Documentation and notifications

h. Any additional patient health documentation or information

Ensure the security of all patients medical documentation (paper and electronic) according to national standards, privacy, and HIPAA policies and guidelines.

Process the release of information requests (FOIA- Freedom of Information Act, or Release of Information) relating to the patient paper medical documents and records, following through assuring completion of request.

Provide clinical information reports as requested by CBP.

Satisfactorily complete all CBP EMR comprehensive training prior to taking on duties and responsibilities of this position.

Attend CBP EMR comprehensive trainings quarterly to stay up to date on any new changes to the CBP EMR system and Medication Application.

Performs other duties and responsibilities as assigned.

Supervisory Controls Works under the administrative direction of the Patient Safety Risk Manager or in his/her absence the Patient Safety Quality Management Director.

In this position, the employee serves as a contractor to the federal government and does not have any federal authority or rights.

Physical Demands This position requires approximately 90% of time using computer, scanner, printer, and telephone; applicant must be literate in their usage.

Able to walk, stand, bend, or sit for extended periods.

Able to reach to retrieve documents or supplies.

Able to carry materials and/or file boxes up to 30 pounds on an infrequent basis or assist patients into/out of a wheelchair.

Must be capable of standing on hard surfaces (cement floors) for long periods.

Must perform the duties in a stressful and often austere environment without physical limitation.

Must be able to respond to a medical emergency and to perform BLS/CPR, as needed.

Vighter LLC is an equal opportunity and affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.