Health Information Management (HIM) Technician (Santa Rosa)

KEY RESPONSIBILITIES:

·         Run daily AIS reports to validate and account for patient discharges, both Inpatient and Outpatient.

·         Pull charts for review and analysis on a timely basis as required by policy and by regulation.

·         Assemble and analyze discharged patient charts and review Inpatient and Outpatient records according to department standards. 

·         Responsible for managing patient health records.

·         Identify chart deficiencies for missing details (i.e., Protected Health Information, signatures, dates, times, and details) and charting.

·         Document deficiency findings using the deficiency tools in software and on corresponding audit forms.

·         Enter deficiencies into AIS.

·         When charts have been completed by the physician or midlevel, reanalyze the pt charts for accuracy and remove deficiencies from AIS accordingly. 

·         Create and maintain patient charts based on established department guidelines.

·         Ensures medical records are assembled in standard order and are accurate and complete.

·         Assist in retrieving charts for stakeholders for chart completion.

·         Retrieve and re-file the patient’s medical records, as needed.

·         File loose filing daily into the proper charts. Prepare charts for patient discharge process.

·         Creates or scans digital images of photos, forms or records to be included in the electronic medical record. 

·         Responds to requests for patient records, both within the facility and by external sources, retrieving them and transmitting them accurately, timely, and appropriately.

·         Process all requests for medical records received by mail, fax, or phone according to State and Federal requirements.

·         Ensure that the release of information is completed properly, timely, and valid.

·         Collaborate with other departments to gather records needed to ensure timely and compliant billing. 

·         Assist in answering telephone and taking accurate messages.

·         Pulling charts for physicians, nursing and other hospital personnel.

·         Perform audits as requested.  

·         Assist in processing dictated and/or transcribed reports.

·         Print reports as needed for timely inclusion into the patient’s active medical record.

·         Work with the physicians, midlevels, and other hospital personnel to answer questions regarding dictation or transcription.  

·         Ensures that errors by outsourced transcription company are corrected and sent to the document’s author for review and signature.    

Requirements

Knowledge and Experience:

·         High school diploma or equivalent. 

·         One year of experience working with medical records preferred.

·         Coursework specific to regulations pertaining to proper administration of medical records preferred.

·         Demonstrated knowledge of patient privacy and security, HIPAA, CMIA, and LPS relative to maintaining medical records required.

·         Knowledge of medical terminology preferred.

Skills and Abilities:

·         Promote patient, physician, customer and employee satisfaction by personal example, treating all contacts with respect

·         Support and participate in activities that foster customer service

·         Communicate and follow the organizational chain of command for notification of patient care/service issues, when appropriate

·         Maintain a complete knowledge base of record completion requirements

·         Maintain consistent productivity and quality of work in a challenging, fast paced and rapidly changing environment

·         Closely adhere to set schedules and timecard procedures

·         Identify, resolve and escalate major issues and service failures that impede success

·         Maintain confidentiality of all patient demographic, medical, and financial information, ensuring proper handling and disposal of confidential documents and adherence to HIPAA

·         Comply with all applicable Federal, State, and local laws, regulations, and requirements as well as PH&S policies and procedures in all aspects of job performance

·         Attend and successfully completes general and department orientation, in-service programs and the annual key competencies and mandatory update requirements

·         Participate actively in department staff meetings

·         Demonstrate effective verbal and written communications

·         Communicate effectively in all interactions in a clear, concise, understandable manner.   

·         Actively seeks constructive feedback and remains open and receptive to it

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