Job description
Hours are 8:00 am to 4:30 pm Monday-Friday.
Summary:
Protects and maintains the security and confidentiality of patient data and medical information.
Ensures integrity of Master Patient Index and all clinical documentation images by performing the functions of prepping, scanning, indexing and quality audits/control of all medical record documents in a timely and accurate manner.
Facilitates electronic health record documentation completion by identifying all deficiencies and assisting physicians in the electronic completion of them.
Handles all aspects of preparation and distribution of information available in the patients’ legal health record as requested by appropriate individuals and hospital departments.
Preserves the integrity of the Legal Health Record and adheres to all policies and procedures.
Position Qualifications Required / Experience Required:
- Assesses and checks scanned images against accuracy and quality requirements. Monitors manual index queues of unassigned images. Ensures accuracy of demographic information. Includes patient merges, baby name changes, and other system updates, etc. Validates interfaces to ensure receipt of clinical information from various systems into the electronic legal health record.
- Performs analysis of documentation and assigns physician deficiencies to ensure timely completion and adherence to regulating agencies requirements. Provides assistance to physicians for completion of patients’ electronic health record. Validates completion of all deficiencies assigned.
- Responsible for document capture of paper record (including prepping, scanning, etc.) into Horizon Patient Folder, and manages electronic images in HPF. Maintains scanning equipment according to procedure.
- Assists with tracking of unbilled accounts: Helps troubleshoot accounts on the Discharged Not Final Billed report to aid department in meeting Accounts Receivable goals, utilizes inter-departmental shared files in order to resolve issues, performs corrections of registration data of patients post discharge.
- Reconciles paper medical records with hospital census to ensure receipt of all patient records.
- Ensures flow of clinical documentation to appropriate work queues for internal and external audits. Performs and participates in quality audits and reviews.
- Maintains paper record storage areas for accessibility until destruction of original documents.
- Discloses patient information to appropriate parties and ensures that information that is released from HIM is in accordance with applicable guidelines.
Position Qualifications Required / Experience Required:
Strong Knowledge of medical record format and content for inpatient and outpatient visits.
Ability to perform computer functions in a Microsoft Windows environment.
Ability to be detail-oriented and perform tasks at a high level of accuracy.
Ability to operate scanning hardware preferred.
Ability to make sound decisions.
Demonstrates good communication and teamwork skills.
Previous experience in a hospital HIM department preferred.
Previous experience with an electronic legal health record system preferred.
Knowledge of medical terminology preferred.
Required Education:
High School diploma or equivalent.
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