Health Information Management Specialist

Overview

Health Information Management Specialist (HIMS) uses office automation systems and various software packages to accomplish assignments (include: medical records audits;

release of information tasks; document and order denial management; patient registrations; transcriptions; patient communications). Reviews own health information management work for accuracy and quantity and maintains all pertinent records.

Pay: $21.99/hr

Schedule: Works Monday through Friday. Shifts may be 8 to 10 hour per day, but will not go over 40 hours a week. Duties will need to be performed at the MFT during core hours (0700-1700).

Responsibilities

• Performs the full spectrum of services of a HIM Specialist. Provides accurate support of digital and physical workflows in the following tasks; medical records audits, medical recordsfile builds, release of information, document and order denial management, patient registrations, transcriptions, and patient communications.
• Provides accurate medical transcription service in accordance with standards set in the Medical Transcription Industry Alliance and in compliance with all security requirements for safeguarding patient information and prevention of Privacy Act violations.
• The HIM Specialist shall provide transcription of dictation on athoc basis and ensure completed transcription is medically consistent and accurate in content. The HIM Specialist shall review dictation for accuracy and meaning to ensure that dictated test results are consistent with associated patient symptoms or diagnoses. The HIM Specialist shall call the originator of the dictation regarding clarification of dictation or questions regarding specific issues. The Specialist shall obtain complete patient data that may involve researching the patient information or contacting the originator.
• The HIM Specialist shall review, code, and analyze medical records to identify inaccurate entries and/or omissions. They shall plan, organize and accomplish the review, analysis and coding of medical records utilizing a variety of means to identify coding requirements. The specialist analyzes patient records that may include multiple injuries, diseases, and/or medical/surgical procedures, determining both accuracy and completeness. They shall determine if/when deviations from proper terminology may indicate omission or inaccuracy within the record and initiate actions to obtain clarification, coordinating work-up of medical charts with staff physician. The HIM Specialist shall examine records and ensure documentation requirements are met. The Specialist shall be responsible for entering record processing data into computer systems for record completion and assisting physicians in the completion of deficiencies.
• The HIM Specialist shall perform releases of medical information. Upon receipt of written requests, the Specialist shall follow standard operating procedures to research, analyze and abstract pertinent information from records that may include multiple injuries, diseases, and/or medical/surgical procedures and reports findings to requestors.
• The HIM Specialist shall make release determinations based upon application of the Privacy Act and other directives covering confidentiality. The Specialist shall verify validity and entitlement to access of information prior to release. They shall send questionable requests to the legal office for review/recommendations.
• The HIM Specialist shall brief patients and agencies such as insurance companies, social services, and medical activities on policies associated with releasing medical information.
• The HIM Specialist shall ensure proper billing procedures are initiated upon completion/fill of request. The Specialist shall initiate, post charges, and forward billing
• statements to appropriate accounting officer for action.
• The HIM Specialist maintains an accurate and detailed record of all requests to ensure proper tracking and reporting. The Specialist shall scan the written authorization and medical record and make copies of records either on paper or electronic media in accordance with
• federal, state, and HIPAA/Privacy regulations.
• HIM Specialists shall treat patient lists as privileged information. Lists and/or names of patients shall not be disclosed to or revealed in any way for any use outside the MTFwithout prior written permission by the SGH, 10th Medical Group.
• HIM Specialists performing transcription work shall release medical information obtained during the course of thiscontract only to other MTF staff involved in the care and treatment of that individual.
• HIM Specialists shall perform registrations of patients using the DoD Electronic Health Record. The Specialist will communicate with staff and patients directly to accurately transcribe personally