Health Information Management

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
· Anticipate the information needs of others
· Demonstrate competency by maintaining positive, constructive interpersonal relationships, and by understanding and practicing the principles of effective teamwork
· Take responsibility to support team members in meeting project milestones and objectives.
· Perform challenging tasks efficiently and effectively
· Show strong, meticulous attention to detail and excellent analytical skills
· Demonstrate performance by adhering to established policies and procedure and exhibiting the defined characteristics associated with attendance and punctuality
· Monitor work queues and perform problem resolution/corrective action where needed
· Analyze medical records for completeness and compliance
· Assign documentation deficiencies to the correct physician, nursing, or other hospital personnel
· Process, scan and index medical records for accuracy, completeness and compliance into the correct paper or electronic medical record
· Confirm authorizations for release of information for requests as necessary
· Respond to business office requests for information and copies of specified documents
Physical Requirements:

While performing the duties of this job, this position is frequently required to do the following:

· Use standard office equipment and access, input, and retrieve information from a computer. Use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.
· Communicate effectively in person or via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population.
· Frequent bending, squatting, kneeling, climbing with the use of a step stool and twisting. Lift and carry up to 20 pounds.
· Sit or stand for minimum periods of one hour at a time. Come and go from the work area repeatedly throughout the day.
· Give and follow verbal and written instructions with attention to detail and accuracy.
· Perform complex mental functions and basic arithmetic functions;
interpret complex laws,regulations, and policies;
collect, interpret, and/or analyze complex data and information.
· Vision:
see details of objects at close range.
· Coordinate multiple tasks simultaneously.
Benefits
Medical
Vision
Dental
401(k)
3.5 Weeks Paid Time Off
$25,000 Life insurance policy is provided at no charge to the employee