This full-time position is responsible for accurately uploading and indexing outside records using applicable software, routing documentation to clinicians as appropriate. The specialist will create or select the appropriate patient, encounter, and/or order while assigning the correct document type and description when indexing into the EHR. They will incorporate internal and external clinical documentation from various electronic and paper sources via applicable software work queues, rounding, eDelivery, or importing into the EHR according to HIM procedures, meeting established benchmarks for quality, accuracy, and productivity. The role requires applying knowledge of medical terminology and nomenclature to identify documentation needs, analyzing medical records for missing documentation and signatures, and assigning/editing deficiencies into the chart management system according to State and Federal regulations. The specialist will also provide support and education to clinicians regarding record completion, collaborate with Data Integrity or other functional areas to communicate errors, and notify appropriate leadership for quality review and privacy investigation. Ensuring clarity, legibility, and proper positioning of scanned documents is crucial, and the specialist will serve as a point of contact for record completion support for clinicians and other providers.
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED