An HIM Associate processes medical records of patients by preparing and scanning the record into the Electronic Health Record System for permanent retention. This position expedites and provides access to patient medical records through the accurate gathering of paper documentation for the Electronic Health Record. Proper performance results in patients and health care workers receiving timely and accurate information and professional staff being able to devote more time to delivery of services. Performance of this position directly impacts accounts receivable and requires attention to turn around times to minimize impact.
Nature and Scope
This position performs health information activities necessary to organize, maintain and use electronic and paper patient health records. This position will process and/or provide electronic health information to various customers in a timely manner; maintain paper and electronic health information in a confidential manner and secure environment.
This position performs functions related to document imaging, chart retrieval pick-up, reception, and basic release of information for continuum of care duties. This position assists internal and external customers by developing and maintaining positive working relationships with other departments, entities, physicians, and outside agencies. This position is expected to safeguard patient information and enforce privacy and confidentiality policies and practices and to adhere to federal and state guidelines. Breaches are to be brought to the attention of HIM Management immediately.
Chart Retrieval Pick-up and Reconciliation:
Obtain new discharged medical records from inpatient and outpatient areas. Process/prepare new discharged records to be scanned. Perform chart tracking functions on records received/leaving the department and reconcile with daily scanned report. Follows up on all missing charts according to standard work and escalates as appropriate/required.
Facility Document Preparation and Scanning:
Reviews and identifies that each page has correct patient identifiers (MRN, HAR, CSN, and patient name) and document type identifier. Scans all documents and ensures barcodes are being read by the scanner and pages are correctly being scanned with no errors or misfeeds. Forwards to quality review at the completion of the work assignment. Escalates errors to management for review.
Ambulatory Document Preparation and Scanning:
Monitors incoming faxes and processes the documents according to the standard work. This includes scanning into the electronic medical record, routing to providers for appropriate notification, routing to medical office for provider follow up. Prepares all paper documents for scanning and scans into the electronic medical record. Documents are routed appropriately based on standard work.
Release of Information:
Perform release of information on continuum of care and patient requests (pertinent information only) based on appropriate authorization and policies and procedures. Ensures compliance with guidelines/requirements related to patient confidentiality and release of information according to established policies and procedures. The incumbent needs to be proficient in basic release of information guidelines from Renown, the state and the federal government in order to correctly answer, handle, or route incoming calls. This position must be familiar with electronic health records, web-based transcription system, TraceMaster view, and Records Management system to be able to produce requested information in a timely and accurate manner.
Individuals assigned to this role will work in conjunction with the Records Coordinator and Inventory Specialists to ensure all boxes at the warehouse are inventoried appropriately and meet the requirements for retention. On an ongoing basis will work to identify boxes that qualify for destruction based on the retention schedule. Scan any documents identified as appropriate storage should be electronic versus paper. Assist with quality reviews of all new boxes being sent to the warehouse for storage.
Support department activities such as answering the phone, providing customer service, and performing back up functions for other positions in the department. Sort and distribute mail and faxes. Assist in new employee and HIM student orientation and training. The high volume of incoming departmental calls challenges this position. Knowledge of all departmental procedures and personnel must be kept current in order to facilitate questions that may arise when performing reception duties. Consistency, accuracy, promptness, and adherence to productivity standards are of paramount importance. This position facilitates the completion of death certificates for employed physicians and residents. An understanding of the state regulations and requirements for a complete death certificate is required.
Work directly with third party vendors as needed in regards to office equipment and maintenance.
This position has the authority to solve problems following established company guidelines. Decisions that must be referred to a supervisor are matters that involved problems which can develop negatively towards the company, time off requests, sick time, work schedules, interoffice problems, etc.
This position does not provide patient care.
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Requirements - Required and/or Preferred
Must have working-level knowledge of the English language, including reading, writing and speaking English.
Requires a minimum of two-year previous office experience, as well as one year of computer experience. Also, must possess excellent communication skills, and have the ability to interact with and troubleshoot physician questions related to electronic medical record completion. Experience with Windows Operating System, EPIC, OnBase, Microsoft Applications preferred. Previous electronic medical record experience preferred. Applicant must be able to work effectively with diverse groups of individuals as well as possess the ability to work well under pressure.
Registered Health Information Technician or other equivalent healthcare certification preferred.
Computer / Typing:
Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.