Health Information Management (HIM) Technician - FT Days - Bethany

Sanford Health•Brainerd, MN

About The Position

The Health Information Management (HIM) Technician reviews and analyzes medical records to identify missing documentation and signatures, compare records with required standards, and enter deficiencies for providers in the electronic medical record (EMR). The role supports timely completion, accuracy, and regulatory compliance of medical records and may be assigned other HIM functions to support departmental workflows. The technician performs record analysis and abstraction, using knowledge of disease processes, anatomy, physiology, medical terminology, coding guidelines, and applicable laws and regulatory standards. Duties include admission and discharge-related work, retrieving prior records, scanning and indexing documents, checking document-imaging accuracy, monitoring record completion, maintaining medical professional information in the EMR, and assigning diagnosis codes based on supporting documentation. The role also processes release-of-information requests, generates reports, supports survey activity, and helps providers and clinicians with EMR use and workflows. The position involves extensive access to protected health information and requires following HIPAA privacy and security requirements, facility policies, and legal regulations. The stated schedule is 8:00 a.m.–4:30 p.m., 32 hours per week, on the day shift.

Requirements

Knowledge of regulatory standards for accurate medical records.
Knowledge of disease processes, anatomy, physiology, and medical terminology.
Knowledge and application of coding guidelines and regulations for diagnosis coding and sequencing.
Ability to use job-specific software, including EMR and document-imaging systems.
Ability to follow HIPAA privacy and security regulations and policies and protect health information.

Nice To Haves

Associate's degree in Health Information or Medical Record Technology.
Experience in health care or long-term care.
Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) credential.

Responsibilities

Analyze medical records for missing documentation and signatures, compare records against required standards, and enter deficiencies in the EMR.
Perform record analysis and abstraction while applying knowledge of medical and regulatory standards.
Use job-specific software, including the EMR and document-imaging systems, and maintain high-level system competence.
Complete admission and discharge functions, including retrieval of previous medical records.
Scan and capture documents promptly and verify their clarity and quality.
Index medical record documents and complete document-imaging accuracy checks and audits.
Monitor timeliness and completion of medical record components for Federal and State regulatory compliance.
Enter and maintain medical professional information in the EMR.
Assign diagnosis codes and sequence them according to supporting documentation, coding regulations, and location and department guidelines.
Support timely and accurate billing by ensuring diagnosis codes are captured for all payers.
Review and process release-of-information requests within requested timeframes and in accordance with policies and legal regulations.
Maintain the security of health information and medical records, follow HIPAA privacy and security requirements, and support and educate others in managing private information.
Prepare and generate reports as requested.
Prepare for and participate in Health Department survey activity.
Support providers and other clinicians in using the EMR and its workflows.
Perform other HIM functions as assigned to support departmental workflows.