HIM Operations Specialist I

Advocate Health and Hospitals Corporation•Charlotte, NC

About The Position

The HIM Operations Specialist I processes and manages internal and external clinical documentation for inclusion in the electronic health record (EHR). The role indexes outside records, routes documentation to clinicians as appropriate, and ensures records are accurately associated with the correct patient, encounter, or order and assigned the appropriate document type and description. Documentation is processed from electronic and paper sources through applicable software, work queues, rounding, eDelivery, or importing, in accordance with HIM procedures and established quality, accuracy, and productivity benchmarks. The specialist reviews medical records for missing documentation and signatures, assigns or edits deficiencies for responsible providers in the chart management system, and supports clinicians with record-completion activities. The role also identifies documentation errors for correction, escalates matters for quality review or privacy investigation, and ensures scanned documents are legible and positioned for end-user review. This position serves as a contact for clinicians and other providers seeking record-completion support.

Requirements

High school graduate or equivalent.
Typically 0–1 years of experience in healthcare.
Proficient computer and keyboarding skills and ability to learn new software systems and electronic communication and meeting platforms.
High attention to detail and accuracy, including when working with frequent interruptions.
Ability to prioritize workload and work under pressure in a fast-paced environment with time constraints.
Ability to work independently and make decisions with minimal supervision while maintaining quality and productivity standards.
Ability to collaborate respectfully in a diverse team environment.
Ability to adapt to a fast-paced environment, switch tasks, and maintain quality and accuracy.
Ability to learn from constructive feedback and take personal ownership for success.
Strong interpersonal and communication skills.
Basic knowledge of HIPAA and ability to safeguard PHI.

Responsibilities

Upload and index outside records using applicable software, routing documentation to clinicians when appropriate.
Create or select the appropriate patient, encounter, and/or order and assign the correct document type and description when indexing into the EHR.
Incorporate internal and external clinical documentation from electronic and paper sources through applicable software work queues, rounding, eDelivery, or importing, following HIM procedures and established quality, accuracy, and productivity benchmarks.
Use medical terminology and nomenclature to identify documentation needs based on patient service areas and level of service provided.
Analyze medical records for missing documentation and signatures and assign or edit medical record deficiencies to the responsible provider in the chart management system according to applicable regulations, medical staff bylaws, and organizational policies.
Provide clinicians with support and education regarding record-completion activities.
Collaborate with Data Integrity or other functional areas to communicate documentation errors for chart correction.
Notify appropriate leadership when quality review or privacy investigation is needed.
Ensure scanned documents are clear, legible, and positioned so they can be read by end users, or indicate the best available quality.
Serve as a point of contact for record-completion support for clinicians and other providers.
Safeguard protected health information (PHI).