Compensation Disclaimer
Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations.
Department: Medical Records/Support Svcs - UH
FTE: 1.00
Full Time
Shift: Days
Position Summary:
Responsible for all entry-level 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. As needed, perform release of Information (ROI) functions to include assisting customers in the Reception area, processing of all types of requests, including continuing care, legal, insurance, disability, subpoenas, Recovery Audit Contractor (RACS) and any other type of requests received to obtain medical records. HIM Tech I staff ensure documentation is accurately indexed to the EHR; as needed perform documentation recreations if documentation is found to need correction due to incorrect format, template, Financial Information Number (FIN), etc. Performs other related duties applicable to the HIM Tech I position description. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.
Detailed responsibilities:
- 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 and ensure documentation accuracy within scanning operation and report identified problems with any assigned function
- INFORMATION REQUESTS - Processes all requests and inquiries for protected health information, 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 – 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; this is in reference to ROI functions, as well as Patient Portal and/or HIM-related matters; provides requestors with authorization forms and/or attestation form to ensure proper completion of forms prior to release of protected health information (PHI)
- CONFIDENTIALITY – Maintains medical records confidentiality and legal requirements
- PPOLICIES AND PROCEDURES - Ensures institutional policies and procedures for administration and maintenance of medical records are adhered to
- TIMELINESS - Process all requests for information in accordance to federal, state and regulatory timeliness guidelines; complete all scanning operational tasks and/or documentation recreations within established timeliness standards
Education:
Essential:
- High School or GED Equivalent
Nonessential:
Education specialization:
Nonessential:
Experience:
Essential:
1 year HIM/medical records experience
Nonessential:
No preferred experience
Credentials:
Essential:
- Not Applicable/Not Required
Physical Conditions:
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:
Essential:
- No or min hazard, physical risk, office environment
