Health Information Management (HIM) Technician - PT - Days

Sanford Health•GSS IA George Comm Ctr, IA

5d•$14 - $22•Onsite

About The Position

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. The Health Information Management (HIM) Technician understands regulatory standards for accurate medical records. Performs record analysis by abstracting and recognizes the relation of a complete medical record. HIM applies knowledge of disease processes, anatomy, physiology, medical terminology, state laws and other regulatory standards in the analysis of the medical record. The HIM 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. The HIM 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. HIM monitors timeliness and completion of various medical record components to assure Federal/State regulatory compliance. Enters and maintains medical professional information in the EMR. The HIM 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. The HIM maintains application of facility policies and standards of practice to ensure release of information requests (ROI) are appropriate and meet legal regulations. Processes ROI requests within requested timeframes. Prepares and generates reports as requested. The HIM 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. The HIM 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.

Responsibilities

Analyze medical records for missing documentation and signatures.
Compare documentation against required standards and enter deficiencies for providers in the electronic medical record system.
Perform record analysis by abstracting and recognizing the relation of a complete medical record.
Apply knowledge of disease processes, anatomy, physiology, medical terminology, state laws and other regulatory standards in the analysis of the medical record.
Utilize job-specific software in analysis and monitoring functions.
Maintain software system competence including the electronic medical record (EMR) and document imaging.
Complete admission and discharge related functions including retrieval of previous medical records.
Scan and capture documents in an extremely timely manner, and confirm capture clarity and quality.
Index medical record documents using document imaging software.
Complete document imaging accuracy checks and audits.
Monitor timeliness and completion of various medical record components to assure Federal/State regulatory compliance.
Enter and maintain medical professional information in the EMR.
Apply knowledge and application of coding guidelines and regulations in the assignment of diagnosis codes and sequencing specific to location and department guidelines.
Assign codes to appropriate medical diagnoses based on review of supporting documentation.
Ensure diagnosis codes are captured for timely and accurate billing for all payers.
Maintain application of facility policies and standards of practice to ensure release of information requests (ROI) are appropriate and meet legal regulations.
Process ROI requests within requested timeframes.
Prepare and generate reports as requested.
Work extensively with protected health information and adhere to HIPAA privacy and security regulations and policies.
Handle requests for release of information according to policies.
Maintain security of health information and medical records.
Support and educate others on managing private information.
Prepare and participate in Health Department survey activity.
Support providers and other clinicians on EMR usage and workflows.