The HIM Operations Specialist I supports health information management operations by accurately incorporating outside and internal clinical documentation into the electronic health record (EHR), routing records to clinicians as appropriate, and supporting medical record completion. The role uses applicable software and work queues to create or select the appropriate patient, encounter, or order and assign document types and descriptions. It applies medical terminology and nomenclature to identify documentation needs based on patient service areas and level of service. The specialist reviews records for missing documentation and signatures, assigns or edits deficiencies in the chart management system, and supports and educates clinicians on record completion. The work must follow applicable state and federal regulations, accreditation standards, Medical Staff Bylaws, and organizational policies. The specialist also communicates documentation errors for chart correction, alerts leadership to quality or privacy concerns, and ensures scanned documents are clear and readable. The role serves as a contact for clinicians and other providers seeking record-completion support.
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED