HIM Technician

Job Summary:

Reviews medical records after discharge for completeness in compliance with the health facility's policies, accrediting organization standards, federal and state requirements. Assures that patient abstracts are correctly entered into the medical record deficiency system. Collects all discharged patient medical records on a daily basis. Prepares medical records and collects loose filing for those discharged medical records for scanning, matching batch header sheets, does quality review, uploads and accepts batches for completeness. Scans and indexes health and administrative information received daily into the health facility's electronic health record system within established timeframes After all information is scanned and indexed, files or destroys the paper files, per policy and procedure. Prepares ED, hospital, and consultant records for scanning: removes staples, places batch header sheets with appropriate medical record and organizes medical records in an orderly manner; assists in a total complete record. Interact closely with the Information Technology Department when discrepancies occur involving the computer system which affects the electronic health record system functions. Maintains an error rate of 5% or less in scanning medical information into the electronic health record system. Combines current patient medical record with any previous patient discharges, if applicable. Assists in quality audits to ensure the integrity of scanned images into the electronic health record system. Places assembled medical records in proper folder according to medical record number and scans them into the Electronic Health Record (EHR). Analyzes medical records of discharged patients for completeness and accuracy according to department and health facility policy and procedures. Monitors deficiencies in the electronic health record that require physician completion. Forwards all analyzed medical records to the Coder. Responsible for coordinating the release of medical information to all requesters, including patients, physicians and other healthcare providers. Verifies authorizations in accordance with health facility policy and procedures and state and federal laws. Responsible for maintaining security and confidentiality regulations for record access and review. Consults director or supervisor of any unusual request. All requests for records are stamped with date received and logged in the correspondence computer. Prepares request for information to be copied by copy services, meeting established guidelines. And notifies requester when records are available Maintains supply closet and orders supplies as necessary. Perform performance improvement audits on each medical record through data collection and documentation review as directed by the director Assists in answering telephone and taking accurate messages. Is familiar with pediatric and OB/GYN medical record requirements. Maintains health facility requirements, policies and standards on confidentiality. Assists in retrieving medical records for physician completion, as applicable. Accepts additional assignments and completes them within a designated timeframe. Must be able to keep up with workload. Maintains a good working relationship within the department and other departments. Protects the confidentiality of patient information, as well as access to computer files and access codes. Supports and maintains a culture of safety and quality.

Professional Requirements:

Adheres to dress code, appearance is neat and clean. Completes annual education requirements. Maintains regulatory requirements, including all federal, state, local regulations, and accrediting organization standards. Maintains patient confidentiality at all times. Reports to work on time and as scheduled, completes work within designated time. Wears identification while on duty, uses computerized punch time system correctly. Completes in-services and returns in a timely fashion. Attends annual review and department inservices, as scheduled. Attend at least 80% of staff meetings annually, reads and returns all monthly staff meeting minutes. Represents the organization in a positive and professional manner. Actively participates in performance improvement and continuous quality improvement (CQI) activities. Comply with all organizational policies regarding ethical business practices. Communicates the mission, ethics and goals of the health facility, as well as the focus statement of the department.

Regulatory Requirements:

High School graduate or equivalent. Two or more years of previous similar health facility experience. Knowledge of accrediting organization standards and state medical record requirements.

Language Skills:

Able to communicate effectively in English, both verbally and in writing. Additional languages are preferred.

Skills:

Basic computer knowledge.

Physical Demands:

For physical demands of position, including vision, hearing, repetitive motion and environment, see the following description. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care. Requirements Resume (if available). Application/Candidate Profile. Immunization record (showing completion of

MMR, HEP

B, Flu, Covid-19 Dose (Comirnaty or Spike) PPD documentation within 1 year. (Individuals with a history of a positive PPD must provide a note for their provider indicating they are free of active disease, a blood test or chest x-ray with the last year.)