Health Information Management/Medical Records

CHSGa•Augusta, GA

1d•Onsite

About The Position

Responsible for acquiring, analyzing and protecting digital as well as traditional medical information vital to providing quality patient care and accurate coding in accordance with federal and state guidelines. If/Once appropriately trained, responsible for the management of accurate diagnosis coding process.

Requirements

Working knowledge of medical terminology
Excellent organizational and prioritizing skills required
Effective and professional verbal, and written communication skills
Communicates well with other associates, patients, family members, and visitors providing warm and friendly greeting and an approachable attitude.
Responds to expressed concerns while displaying a helpful, caring demeanor, answers questions when appropriate in a professional manner.
High school diploma or equivalent.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals.
Ability to write routine reports and correspondence.
Ability to speak effectively before groups of customers or associates of the organization.
Ability to add, subtract, multiply and divide in all units of measure, using whole numbers, common fractions, and decimals.
Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram format.
The ability to deal with problems involving several concrete variables in standardized situations.
Proficiency with Microsoft Office (Outlook, Word, Excel, Power Point)
Use of Printers and Scanners

Nice To Haves

Training in Diagnosis Code Management, preferred.

Responsibilities

Coordinates with center “super users” to ensure access controls in place for the electronic medical record.
Conducts audits of records for completion based on current clinical standards of practice.
Maintains paper records according to retention schedule.
Process requests for records from any outside entity.
Maintains effective communication with others, both inside and outside the department.
Coordinates with Administrator to ensure Center’s compliance with privacy and security requirements.
If/Once appropriately trained, performs diagnosis coding and maintenance of diagnosis for clinical records.
Maintains necessary journals specific for HIM functions.
Participates in Nursing Center surveys (Licensure / JCAHO) and any subsequently required reports.
Attends and participates in continuing educational programs to keep abreast of changes in field of practice as well as to maintain current license/certification, as required.
Attends and participates in mandatory in-services.
Honors patient’s rights to fair and equitable treatment, self-determination, individual privacy, property and civil rights, including the right to wage complaints.
Complies with Corporate Compliance and Security and Privacy programs.
Participate in QAPI, Morning Meeting, Utilization Review and other meetings as indicated.
Follows established safety procedures when performing job tasks and/or working with equipment.
Reports job-related functions/tasks that involve occupational hazards including exposure to blood and body fluids and others as necessary.
Follows established safety regulations, to include fire protection/prevention, smoking regulations, infection control, etc.
Promotes the image and reputation of the System by exhibiting servant leadership and providing direct and open lines of communication.
Contributes to the work of committees, workgroups, project management, and other collaborative efforts of the System.
Performs other duties as necessary to ensure the success of the System.