SHSMD Career Center

Position Summary:Performs all required clerical HIM functions: Preps and scans documents according to departmental procedures to meet scanning timeliness and productivity, performs quality checks of scanned documents and final validation of paper documents prior to committing to the Electronic Health Record (EHR). Processes all requests for medical records ensuring disclosures follow HIPAA guidelines and minimum necessary requirements. Release of Information (ROI) functions include assisting customers in the Reception area, processing of all types of requests, including continuing care, attorney, insurance, disability, subpoenas, Recovery Audit Contractor (RACS) and any other type of requests received to obtain medical records. Electronically process and track RAC, ADR and other third party payer requests. Uploads images and performs film library functions. This position processes pended transcription documents, problem solves missing transcription, reviews medical records for completeness and assigns provider documentation deficiencies in the EHR (CERNER). HIM Tech I staff ensure documentation is placed in the correct location within the legal health record (LHR), communicate with providers to complete and/or dictate missing reports required for medical record completion and resolve provider documentation issues within the EHR. A core function is Master Patient Index (MPI) management, revising/updating patient demographic information in the LHR. Completes trauma & stroke alerts and investigates any encounter issues as assigned. Provides assistance in coordinating records sent/retrieved from offsite storage. Analyzes assigned documentation criteria to report compliance statistics and data. Performs other related duties applicable to the HIM Tech I position description. Adherence to Hospitals and departmental policies and procedures is required. No patient care assignment. Trauma & Stroke AlertsAccountability:

ANALYSIS - Completes chart analysis of all discharged medical records for inpatient, day surgery, and observation discharges. Reviews H&Ps, Operative Reports, and Discharge Summaries to ensure they meet CMS/TJC documentation requirements. Assignment of provider deficiencies when appropriate documents are missing or not authenticated per medical staff rules, regulations, and department guidelines

QUALITY - Works as part of the team to identify process issues and report identified problems with any assigned function

TIMELINESS - Process all requests for information in accordance to federal, state and regulatory timeliness guidelines. Complete all reviews and documentation processing within established timeliness standards

REVIEWS - Completes chart analysis of all discharged medical records for inpatient, day surgery, and observation discharges. Reviews H&Ps, Operative Reports, and Discharge Summaries to ensure they meet The Centers for Medicare and Medicaid Services (CMS) The Joint Commission (TJC) documentation requirements. Assignment of provider deficiencies when appropriate documents are missing or not authenticated per medical staff rules, regulations, and department guidelines

INFORMATION REQUESTS – Processes all requests and inquiries for protected health information including Film Library imaging requests, dispersing the information with accountability to all regulatory entities and according to the facility’s policy and procedures. Obtain proper signatures for release of information in order to comply with disclosure requirements in accordance with federal and state regulations. Invoices, records and processes funds received from requesters

DATA – Enters all required data necessary for tracking disclosures within a software application. Use electronic medical records and supporting applications to retrieve necessary data for disclosures is required

RECORDS - Create and maintain daily records of work performed

CUSTOMER SERVICE - Responds to additional service or special requests in a timely manner; ensures customer issues are appropriately resolved; demonstrate positive customer relations. Assists patients and families in completing required forms, locating documents, and referring them to the appropriate services and resources. Processes urgent provider requests for protected health information in order to continue patient care

COMMUNICATION – Answers all front desk calls and assist in providing coverage for walk-in patients and customers. Provides requestors with authorization forms and ensures proper completion of authorizations are present prior to release of protected health information (PHI)

CONFIDENTIALITY – Maintains medical records confidentiality and legal requirements

EDUCATION – Assists with guidance to staff in required HIM Tech duties to include prepping/scanning/Quality Assurance (QA), chart analysis, transcription management and release of information

POLICIES AND PROCEDURES - Ensures institutional policies and procedures for administration and maintenance of medical records are adhered to

DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops

Education Requirements:

High School Diploma or GED equivalent

Experience Requirements:

1 year health care setting experience

Education Requirements - Preferred:

Associate's Degree in related discipline

Physical Demands Requirements:

Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working Conditions Requirements:

No or min hazard, physical risk, office environment