Job Title:

Full Time Health Information Management Specialist Reports to:

Director of Operations Description:

The Health Information Management (HIM) Specialist is responsible for overseeing the integrity, security, accuracy, and accessibility of Behavioral Health Clinic's health records. This position ensures compliance with HIPAA, state and federal regulations, accreditation standards, and organizational policies while supporting clinical, operational, and revenue cycle functions. The HIM Specialist serves as the primary resource for medical record management, release of information, documentation standards, record retention, and compliance related to patient health information.

Duties and Responsibilities:

Health Information Management Maintain complete, accurate, and timely electronic health records (EHR). Perform routine chart audits to ensure documentation meets organizational standards. Monitor chart completion and follow up with providers regarding missing or incomplete documentation. Ensure proper indexing, scanning, retention, and organization of electronic medical records. Maintain record retention and destruction schedules in accordance with organizational policy and regulatory requirements. Release of Information (ROI) & Health Information Requests Serve as the primary point of contact for all medical record requests, ensuring timely, accurate, and compliant responses. Process and fulfill requests for medical records in accordance with HIPAA, state and federal regulations, and organizational policies. Verify authorizations and maintain documentation of all disclosures of Protected Health Information (PHI). Coordinate medical record requests from insurance companies, patients, providers, attorneys, and other authorized entities. Serve as the central resource for insurance-related documentation requests, audits, appeals, and utilization reviews, working closely with Billing and Clinical teams to ensure complete and timely submissions. Monitor payer communications for changes to documentation or medical record requirements and ensure updates are communicated to appropriate departments and providers. Maintain tracking and reporting processes for medical record requests to ensure compliance with turnaround times and regulatory requirements. Documentation Quality & Compliance Conduct documentation quality audits. Identify documentation deficiencies and collaborate with providers to improve documentation standards. Assist with policy and procedure development related to medical records and documentation. Support regulatory surveys, payer audits, and accreditation reviews involving medical records. Collaboration Partner with the HIPAA Compliance Officer on privacy-related matters, investigations, and regulatory requests involving protected health information. Work closely with Billing, Credentialing, Clinical Leadership, and Operations to ensure accurate, complete, and compliant health records. Educate staff on documentation standards, medical record workflows, and health information management best practices.

Qualifications:

Education Associate's degree in Health Information Management or related healthcare field required. Bachelor's degree preferred. Experience Minimum 2 years of Health Information Management, medical records, or healthcare compliance experience preferred. Experience within behavioral health strongly preferred. Experience with electronic health record systems. Preferred Certifications Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Coding Specialist (CCS) (preferred but not required) Certified in Healthcare Privacy and Security (CHPS) (preferred)

Benefits:

Starting hourly range: $24,00 - $30.00 (based on experience and qualifications) Comprehensive healthcare benefits, including Medical, Dental, Vision, Short-Term Disability (STD), Long-Term Disability (LTD), and Retirement Plan options Supportive and collaborative team environment with opportunities for professional growth and career advancement Paid Time Off (PTO) and paid holidays