Health Information Management (HIM) Technician (Santa Rosa)

Northern California Behavioral Health System•Santa Rosa, CA

2d•$25 - $31•Onsite

About The Position

The Health Information Technician is responsible for analyzing medical records for completeness and compliance in accordance with federal and state regulatory guidelines, the Joint Commission standards, Medical Staff By-Laws/policies and procedures, Rules and Regulations, and HIM department policies and procedures. This includes reviewing medical records for completeness and assigning deficiencies to appropriate clinical and nursing staff, monitoring deficiency analysis work queues and resolving related problems. The HIM Technician is a resource for continuum of care services to hospital staff, medical staff and patients. This role is responsible for rounding on the units to gather, process, scan and index medical records for accuracy, timeliness, completeness and compliance in accordance with federal and state regulatory guidelines, Joint Commission standards, Medical Staff By-Laws/policies and procedures, and HIM department policies and procedures. This includes scanning all record types into the electronic medical record system ensuring documents are properly indexed, boxed and stored according to retention and retrieval guidelines. Responsibilities may include (but are not limited to) operational department coverage, patient calls, facilitating quick retrieval of and/or process of specific requested documentation to ensure safe and quality patient care services. The Health Information Management Clerk maintains knowledge of, participates in further training provided, and understands the potential risks regarding occupational health hazards (e.g. bloodborne pathogen exposures).

Requirements

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.

Nice To Haves

RHIT credential preffered

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.
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