Health Information Management (HIM) Technician - Full Time Days

Sanford Health•Saint Paul, MN

12d•Onsite

About The Position

Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America’s heartland. This role understands the necessity for timely completion of medical record documentation by analyzing medical records for missing documentation and signatures. Compares the documentation in the medical record against required standards and enters deficiencies for providers in the electronic medical record system. May be assigned other HIM functions to support departmental workflows. Understands regulatory standards for accurate medical records. Performs record analysis by abstracting and recognizes the relation of a complete medical record. Applies knowledge of disease processes, anatomy, physiology, medical terminology, state laws and other regulatory standards in the analysis of the medical record. Utilizes job specific software in analysis and monitoring functions. Maintains software system competence including the electronic medical record (EMR) and document imaging at a high level. Completes admission and discharge related functions including retrieval of previous medical records. Scans and captures documents in an extremely timely manner, and confirms capture clarity and quality. Indexes medical record documents using document imaging software. Completes document imaging accuracy checks and audits. Monitors timeliness and completion of various medical record components to assure Federal/State regulatory compliance. Enters and maintains medical professional information in the EMR. Requires knowledge and application of coding guidelines and regulations in the assignment of diagnosis codes and sequencing specific to location and department guidelines. Assigns codes to appropriate medical diagnoses based on review of supporting documentation, and ensures these are captured for timely and accurate billing for all payers. Maintain application of facility policies and standards of practice to assure release of information requests (ROI) are appropriate and meet legal regulations. Processes ROI requests within requested timeframes. Prepares and generates reports as requested. Will work extensively with protected health information and is required to adhere to health insurance portability and accountability act (HIPAA) privacy and security regulations and policies related to the same. Handles requests for release of information according to policies, and maintain security of health information and medical records. Supports and educates others on managing private information. Prepares and participates in Health Department survey activity. Supports providers and other clinicians on EMR usage and workflows.

Requirements

Associate's degree in Health Information or Medical Record Technology preferred.
Experience in health care or long-term care preferred.
Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) preferred.
Adherence to health insurance portability and accountability act (HIPAA) privacy and security regulations and policies.

Responsibilities

Analyzes medical records for missing documentation and signatures.
Compares documentation against required standards and enters deficiencies for providers.
Performs record analysis by abstracting and recognizing the relation of a complete medical record.
Applies knowledge of disease processes, anatomy, physiology, medical terminology, state laws, and regulatory standards in medical record analysis.
Utilizes job-specific software for analysis and monitoring.
Maintains high-level competence in software systems, including EMR and document imaging.
Completes admission and discharge related functions, including retrieval of previous medical records.
Scans and captures documents in a timely manner, confirming clarity and quality.
Indexes medical record documents using document imaging software.
Completes document imaging accuracy checks and audits.
Monitors timeliness and completion of medical record components for regulatory compliance.
Enters and maintains medical professional information in the EMR.
Applies coding guidelines and regulations for diagnosis code assignment and sequencing.
Assigns codes to medical diagnoses based on supporting documentation for timely and accurate billing.
Maintains facility policies and standards for release of information (ROI) requests.
Processes ROI requests within requested timeframes.
Prepares and generates reports as requested.
Adheres to HIPAA privacy and security regulations related to protected health information.
Handles requests for release of information according to policies and maintains security of health information.
Supports and educates others on managing private information.
Prepares for and participates in Health Department survey activity.
Supports providers and clinicians on EMR usage and workflows.