Data Entry Medical Records Manager

Herminia M. Vasquez

*** *. *** ****** · San Antonio, Texas 78237 · Cell 210-***-****

· E-mail: ****.****@*****.*** and/or ********@*****.***

OBJECTIVE:

Highly motivated and results oriented Medical Records Manager and Clinical Data Coordinator with over 20 years of experience seeking a leadership position within a fast pace healthcare environment. Proven ability to optimize recordkeeping process, ensure data accuracy ad compliance to lead a team toward achieving departmental goals. Eager to apply expertise to improve departmental efficiency and help contribue to the organization's continued success.

Summary of Qualifications

Medical Records Manager (Electronic or Paper)

.. Clinical Data Specialist

..Data entry, Analyze, Optimise and check data accuracy.

Organizing and maintaining patient health history information and data

Clinical Quality Control/ Audit patient charts for accuracy

.. Team Player, will help anyone who needs my help.

.. Uphold HIPAA compliant regulations and protocols.

Ability to handle high work demands, pressure of deadlines and excellent attention to detail.

Respond to continuous flow of requests and manages incoming work quickly and accurately

Adaptable, self-motivated and energetic self-starter with excellent problem solving skills

Always work to the best of my ability

Bilingual – Fluent in English and Spanish (read, write and speak both languages)

Skills;

Knowledge of modern office equipment

Interpersonal/human relations skills

Organizational skills

Telephone etiquette skills

Ability to maintain records and files

Ability to operate personal computer

Ability to maintain confidentiality

Ability to exert physical effort maintaining and distributing files

Organize and manage patients' health information data.

Ensure paperwork is properly filled out.

Verify accuracy and accessibility of files.

Certified in Microsoft Word, Excel, Access, Power Point, Outlook, Medical Manager, Study Manager and CDS = (Clinical Data System)

Certified in Training for EHR/EMR Electronic System (NextGen)

Certified in Bookkeeping, filing

Fast paced/ Multi-tasking experience

Certified in Accounts Payable/ Accounts Receivable (Have not had the opportunity in using my knowledge)

Receptionist/ Front Office Clerk, Check in, check out patients.

Work Experience

Medical Records Manager

Normandy Terrace Nursing and Rehabilitation. Jul. 2022 - Jul. 2024

Maintain MR office in excellent order. Create new patient charts but Normandy Terrace has now gone paperless due to my entering patient data into PCC. Scan and file every document that comes to the facility. Research and analyze data reports before releasing. Analyze and check every data entry for 100% accuracy. Create discharge summary for every discharged resident. Help train and direct nurses on new changes in the medical records department. Prepare ADR's, medical records requests, Physician requests etc.

Streamlined medical records system by implementing a paperless system using Point Click Care (PCC). Improving efficiency and data accessibility at this facility..Established and conducted regular internal audits ensure 100% accuracy. Utilized a hybrid electronic/paper system to manage resident clinical records in a fast and precise manner.

Championed HIPAA compliance policies. Cultivate professional and friendly relationships with Medical Directors, Physicians and Nurse Practitioner and prepare documents for their signatures on labs, imaging reports etc.

Sunrise Nursing and Rehabilitation Nov. 2017 - Jul. 2022

Medical Records Manager

Medical Records Responsibilities:

Most importantly, I respect the privacy and the concerns of all residents. Follow HIPAA compliance and protocols.

I have a variety of tasks to perform such as order all supplies needed for all the nursing patients. In charge of the front (receptionist), answer phones, direct phone calls. Data entry, scan and file into PCC. Prepare all records requested, including ADR's. Manage the storage and destruction of discharged residents. Check labs and all ultrasounds for discrepancies before delivery to physicians for signatures. Positive, professional and friendly relationships with medical director/ nurse practitioners. Check and double check data entry for 100% accuracy.

Manage medical records department, organization of all records and keeping records in a secure manner. create, maintain, prepare, coordinate and check for accuracy of the charts. I have a variety of tasks to perform including going to our sister location (Northgate N&R) to do the same tasks due to no medical record staff member.

Develop medical records systems and spreadsheets. Interact with a variety of medical professionals and build a bond with patient families. Create and maintain medical records in accordance to facility policies and state and federal regulations. Respectful, professional and positive relationship with the Medical Director, Physicians and Nurse Practitioner. Championed HIPAA compliance initiatives within changes of the HHS.

Medical Records Tasks:

Prepare medical records charts for admissions, discharges and patient requests. Coordinate chart audits, checking for completion. Organize, test and ensure search ability and access to medical documents. Create, order, maintain and distribute forms, templates and report documents. Purge and archive outdated records in a designated storage area. Keep a record as to who is in storage and number each box for easier retrieving purposes. Create a template as to where each record is kept. Collect information, compile statistical data and prepare records. Determine appropriate release of medical records by verifying identity and purpose of the requester. Establish and maintain procedures to be followed regarding collection, indexing and retrieval/filing of medical records. Audit charts for accuracy in filing. Contact providers on delinquent medical reports and inform concerned departments of any errors. File paper documents into charts.Thin and file correspondence from paper chart to file in Active charts in medical records.

Maintains patient files and retrieves files for scheduled appointments; files study patient charts; files all patient data upon receipt of information; initiates records for new patients and creates computer index; prepares file labels; maintains filing statistics; audits filing sequence, Responds to requests for medical records; processes letters and reports; answers and directs telephone calls, retrieves patient schedules from computer system; distributes lab reports to physicians, and materials to other departments; requests information from various departments; responds to correspondence requests.

Sends and receives information via facsimile machine electronically.

Keeps Physician/Nurse Practitioners informed of problems or issues; monitors supplies needed; performs other duties as assigned.

The Village @ Incarnate Word Oct. 14, 2015 – Oct. 2017

Medical Records Manager

Maintain medical records office in excellent order file and thin charts. Have developed a schedule for thinning the medical records. Tend to all faxes and direct them to nurses. Point Click Care training. Enter new staff into PCC and give them access into PCC. Enter in PCC telephone orders. Create a log of all telephone orders mailed out. Make sure telephone orders are written accurately before entering them. Print MARS/TARS on a monthly basis. Make a copy of MARS/TARS and place in chart while waiting for their return. Print and replace Face Sheets every 1st of the month. Mail out telephone orders to physicians and keep a copy (pink) of them until they are returned. Print consolidated orders and mail to the residents designated doctor outside of the facility and make a copy and place in chart while they are mailed back this way I know who I received back. Send out census reports as soon as new admissions or discharges occur within the facility. Discharge residents from PCC. Make sure everything in the new patient chart is complete. Check for accuracy foremost. Maintain a list of hospice residents. Maintain a list of when they were taken to hospital and their return. Maintain a list of physician and their residents who do not acquire the Medical Director as their physician. Maintain a log of TB, pneumonia, shingles, influenza (in season) immunizations, In charge of taking notes (minutes) in on our QAPI meetings then sending out to every QAPI member a copy of what was discussed. Call in to DADS when a resident expires at the facility. Maintain all resident records such as Face sheets, DNR/Full code status, MARS/TARS in case of emergency. HIPAA regulator. Fax Long Term Care insurances for all our LTC residents at the beginning of the month. Print a copy of all the residents’ diet and give to the Dietary Director. Take care of the front office while the receptionist is away from her desk. Check all Physician notes after their visits with the resident for new medical diagnosis then give to nurses to follow up if any new orders were given. Audit charts constantly. Create charts for all our residents. Enter all our physicians’ addresses into our database including NPI #’s. Keep track of all consolidated orders sent out for signatures. Call and remind physicians of their visits with their residents once they are due. Create a list of physician and their residents. Divide all resident thinned charts with different colored paper to make access to finding paperwork easier. Box discharged charts into our storage area and note when the discharge happened and when to destroy the documents but also keep a copy of who I stored. (Kept for 6 years). Break down discharges residents into thinned charts.

State Survey 2016 = 0 Demerits

Can provide Compliance visit reports from the Management Consultant (RHIT).

NE Endo Associates March 2011 - Oct. 2015

Medical Records Coordinator

Maintains patient files and retrieves files for scheduled appointments; files study patient charts; files all patient data upon receipt of information; initiates records for new patients and creates computer index; prepares file labels; maintains filing statistics; audits filing sequence. Audits each and every record for accuracy.

Responds to requests for medical records; processes letters and reports; answers and directs telephone calls.

Retrieves patient schedules from computer system; distributes lab reports to physicians, and materials to other departments; requests information from various departments; responds to correspondence requests.

Sends and receives information via facsimile machine electronically.

Keeps Physician/Nurse Practitioners informed of problems or issues; monitors supplies needed; performs other duties as assigned.

Audit and analyze each and every record for accuracy.

Training in EHR/EMR Electronic System (NextGen)

Directly supervise the discharge/receiving of medical records

Maintain patient confidentiality

Prep charts for daily visits

Added all patients charts to electronic system, no more charts in office ( ALL CHARTS)

Tend to all faxes coming in, distribute to appropriate MA to give to Physicians

Prepare medical records for insurance companies, doctors’ offices, law firms, disability companies, and for patient requests

Call and ask for fees when applicable

Assembly of patient records

Request medical records from all hospitals for hospitalized patients

Organization of all paperwork for no intermingling

Scan and file everything (paper) they bring in to add to their patient chart

Scan and file new patient packets and their physician not, labs etc. for their upcoming visit

Scan and file all prescription and their fax confirmation

Scan and file all STRIC orders, and/or lab orders, IPRO’s, Insulin Pump download, physician correspondence, lab results,sono’s

Check for abnormalities

Receptionist/ Front Office Clerk, Check in, check out

Invisions Consultants LLC March 2010 – March 2011

Clinical Research Data Coordinator, Quality Control/Audit

Job Duties:

The only Research Data Coordinator @ Invisions Consultants LLC

Manage 10-25 eCRF studies (4 laptops) and 5 paper CRF’s

Receives original complete source document visits

Read eCRF or CRF Data Entry Guidelines

Transfers collected data from source documents into CRF or eCRF’s.

Maintains original source document data in charts

Arranges monitor visits and hosts monitor at monitoring visits

Communicates with PI and CRC’s for data clarification

Assemble patient charts, file source documents

QA charts for accuracy prepare charts/CRF for monitor, tend to monitor needs

Tend to all Query Resolutions (except SAE’s)

Call received study drug or non-drug into IVRS

Study Drug Accountability – Tend to Drug Log

Radiant Research N.E. March 2007 – Oct 2009

Clinical Research Data Management, Quality Control/Audit

Job Duties:

*All of the above mentioned.

Healthcare Discoveries Inc. January 18, 2006 – February 2007

Clinical Research Data Coordinator

*All of the above mentioned except not in management just one of 4 Research Data Coordinators

SAMCRC November 2002 – January 21, 2006

Medical Records Supervisor

Maintaining Medical Records (CRF) room in excellent order

Archiving and filing, request, receive, fax and mail medical records

Assemble charts for new subjects, fax and distribute all department faxes

Open and distribute mail accordingly

Stamp, date and evaluate lab results to determine results for CS or NCS

QA every subjects charts for accuracy, make sure all labs, mammo’s and ECG’s are filed and have been evaluated by P.I.

Send resolved queries via Fed-Ex, UPS and/or DHL

Resolve Queries

Data Entry

Make ready CRF’s/charts for data management to resolve issues

Tend to patient/doctor personnel medical record needs

Education

Texas Careers December 2001 – September 2002

Certified in Computer Office Technology

4.0 GPA

Perfect Attendance***Certificates of Participation

GCP - Guideline Certified

HIPAA Certified

Basic GCP Training

Data Entry EDC Trainings

Achievement Awards

References Upon Request

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