Health Information Specialist

Hope Springs Care Center•Montrose, CO

About The Position

The Health Information Specialist maintains medical records in accordance with federal and state guidelines and the company's established policies and procedures. The role supports admission, transfer, discharge, record organization, auditing, information requests, and related documentation processes in a healthcare facility.

Requirements

High school diploma or equivalent required.
One to two years of healthcare-related experience preferred; prior experience in a skilled nursing environment is desirable.
Knowledge of medical terminology preferred.
Ability to work beyond normal working hours, on weekends and holidays, on other shifts, and in other positions when necessary.
Ability to read, write, and speak English sufficiently and comprehensibly to perform the essential job functions.
Knowledge of nursing and medical practices and procedures, terminology, laws, regulations, and guidelines pertaining to long-term care.
Sufficient computer skills, including proficiency in Microsoft Office, Outlook, and/or the Internet, to perform required duties.

Nice To Haves

Prior experience in a skilled nursing environment.
Knowledge of medical terminology.

Responsibilities

Comply with company and departmental policies and procedures.
Assist with preparing medical records for new admissions and completing data required for licensing, certification, and facility procedures.
Assemble new admission registers; index and code diagnoses.
Perform data entry for MDS and physician orders as directed.
Conduct medical record audits and re-audits and submit them to appropriate parties.
Collect and organize charts, inspect them for completion, and return incomplete records to nursing service for correction.
Maintain records of authorized information taken from charts, including the information type, recipient, date, and department.
Ensure medical records removed from the department are signed out and signed back in upon return.
Abstract authorized or required information for insurance companies, Medicare, Medicaid, VA, and other parties.
Index medical records as directed.
Mail physician telephone orders daily; track their return and notify the supervisor about delinquent physicians.
Prepare reports for physicians as necessary.
Thin and file medical records regularly, including active and inactive records, in accordance with established policies.
Retrieve medical records for authorized personnel, including physicians, nurses, and government agencies or personnel.
Assist with transfer and discharge processes as necessary.
Complete Medicare certifications and recertifications.
Assemble discharge records, obtain a discharge summary for each, and follow up as indicated.