Health Information Management Specialist

NURSING & THERAPY SERVICES OF COLORADO•Colorado Springs, CO

2d•$22 - $24•Onsite

About The Position

Performance Expectations for All Employees: Protects confidential information and understands responsibilities regarding the Health Insurance Portability and Accountability Act (HIPAA) and Protected Health Information (PHI). Complies with safety instructions, observes safe work practices, and provides input on safety issues and promotes a safe work environment. Consistently demonstrates the agency’s mission to provide quality services for all clients to allow them to remain in their homes and live with independence and dignity for as long as possible. Meets the agency’s expectations for exemplary customer service. Pursue learning opportunities to enhance professional capabilities. Adheres to all agency policies and procedures. Complies with all local, state, and federal laws and regulations. Attends required meetings. Performs other job-related duties as assigned or required. Essential Job Functions/ Responsibilities: Manage the collection, storage, retrieval, and usage of patient health information. Perform concurrent and retrospective medical record reviews to ensure documentation completeness, accuracy, timeliness, and regulatory compliance. Establish a means to fax, review and track all orders within the required time and follow up when necessary. Track all physician credentials, NPI verification, and electronic signatures. Create and maintain tracking logs for orders, notes, requests, and other outside company communications. Update and track all address changes and updated packets. Ensure compliance with HIPAA, HITECH, CMS, Medicaid and state health information regulations. Ensure all required documentation (orders, plans of care, OASIS, visit notes, physician signatures) is completed, signed, dated, and filed within required timeframes. Track and resolve documentation deficiencies, including late, missing, unsigned, or inconsistent records. Implement, maintain, and validate EMR and health information systems, ensuring record integrity throughout the client lifecycle. Maintain confidentiality while ensuring appropriate access to health information in accordance with privacy and retention laws. Conduct internal HIM audits and support Quality Assurance and Performance Improvement (QAPI) activities through data analysis, reporting, and improvement recommendations. Support external audits, surveys, and investigations by assembling, validating, and presenting requested records and documentation. Scan, name/title and file home health documentation into EMR while ensuring integrity of care plan is maintained; if discrepancy is found, notify appropriate personnel to rectify as instructed. Complete mailings and scanning projects as needed. Perform general filing and record maintenance. Make sure EMR storage access and copy requests preservation are completed as requested. Develop, update, and maintain HIM policies, procedures, and processes including record corrections and amendments. Collaborate with clinical leadership, compliance, IT, quality and billing teams to address documentation trends and system issues. Provide training, guidance, and subject-matter expertise to staff on documentation standards, best practices, and system use.

Requirements

Proven experience in health information management.
Experience with Electronic Medical Records (EMR) systems.
Experience in a home health or healthcare setting.
Familiarity with healthcare data analytics.
Knowledge of coding systems like ICD-10 and CPT.
Strong understanding of healthcare compliance and regulations.
Proficient in the use of health information systems and EMR software.
Strong knowledge of medical terminology and healthcare procedures.
Excellent organizational and communication skills.
Attention to detail and a commitment to accuracy.
Ability to maintain patient confidentiality and adhere to ethical standards.
Problem-solving skills and the ability to work under pressure.
Basic understanding of healthcare laws, privacy practices, and coding systems.

Nice To Haves

Certification as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT), preferred but not required.

Responsibilities

Manage the collection, storage, retrieval, and usage of patient health information.
Perform concurrent and retrospective medical record reviews to ensure documentation completeness, accuracy, timeliness, and regulatory compliance.
Establish a means to fax, review and track all orders within the required time and follow up when necessary.
Track all physician credentials, NPI verification, and electronic signatures.
Create and maintain tracking logs for orders, notes, requests, and other outside company communications.
Update and track all address changes and updated packets.
Ensure compliance with HIPAA, HITECH, CMS, Medicaid and state health information regulations.
Ensure all required documentation (orders, plans of care, OASIS, visit notes, physician signatures) is completed, signed, dated, and filed within required timeframes.
Track and resolve documentation deficiencies, including late, missing, unsigned, or inconsistent records.
Implement, maintain, and validate EMR and health information systems, ensuring record integrity throughout the client lifecycle.
Maintain confidentiality while ensuring appropriate access to health information in accordance with privacy and retention laws.
Conduct internal HIM audits and support Quality Assurance and Performance Improvement (QAPI) activities through data analysis, reporting, and improvement recommendations.
Support external audits, surveys, and investigations by assembling, validating, and presenting requested records and documentation.
Scan, name/title and file home health documentation into EMR while ensuring integrity of care plan is maintained; if discrepancy is found, notify appropriate personnel to rectify as instructed.
Complete mailings and scanning projects as needed.
Perform general filing and record maintenance.
Make sure EMR storage access and copy requests preservation are completed as requested.
Develop, update, and maintain HIM policies, procedures, and processes including record corrections and amendments.
Collaborate with clinical leadership, compliance, IT, quality and billing teams to address documentation trends and system issues.
Provide training, guidance, and subject-matter expertise to staff on documentation standards, best practices, and system use.