Health Information Management Technician - Full-time

Profile

Health Information Management Technician - Full-time

Department:

HIM

Location:

Rio Rancho, NM

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Job Summary and Scope

Retrieval of paper medical records for processing to EMR. Process the paper medical record by reviewing documentation to ensure it is approved for including in the legal medical record. Perform scanning, quality checking and validating functions. Ensure all documentation meets hospital requirements and is placed in the correct location. Prep and scan documents according to departmental procedures to meet scanning timeliness and productivity. Review medical records for completeness and assign provider documentation deficiencies in the EMR. Communicate with providers to complete and/or dictate missing reports needed for coding and billing. Resolve provider documentation issues within in the EMR. Process requests for information ensuring all disclosures follow HIPAA guidelines and minimum necessary requirements. Expedite urgent requests for information. Ensure adherence to Hospitals and department policies and procedures. Perform other related duties as assigned. No patient care assigned.

Essential Functions:

POLICIES AND PROCEDURES - Maintain established departmental policies and procedures, objectives, and quality assurance programs

PROFESSIONAL DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops

Review information contained in documentation to ensure it is in an approved format. Provide daily chart analysis of all medical records for inpatient, day surgery, and observation discharges to ensure TJC accreditation. Review H&P, Operative Reports and Discharge Summaries to ensure they meet CMS documentation requirements. Assign provider deficiencies when appropriate documents are missing or not authenticated per medical staff rules, regulations and department guidelines

Maintain medical record confidentiality and legal requirements.

Work as a team to identify process issues and report identified problems with document preparation, scanning, quality check, or validation, be technical or clerical staff

Process all requests for information in accordance to federal, state and regulatory timeliness guidelines. Complete all reviews and documentation processing within established timeliness standards

Process urgent requests for records for continued care; release all information according to HIPAA standards.

Ensure institutional policies and procedures for administration and maintenance of medical records

Follow up to determine reliability of treatment used; change method and degree of therapy when appropriate

Create and maintain daily records of work performed

Respond to additional service or special requests in a timely manner; endure customer issues are appropriately resolved; demonstrate positive customer relations

Perform miscellaneous job-related duties as assigned.

SRMC Core Values

Integrity:

Our words and actions match our values

To Serve:

We put the needs of others before our own

Excellence:

We strive to exceed expectations and/or standards in every activity, every encounter, and every initiative

Safety/Quality:

We provide evidence based care, programs, services, and an environment that achieves the best outcomes

Teamwork:

We enjoy the ability and power to work collaboratively to deliver exceptional service

Communication Skills

Professional communication, both written and oral.

Required Qualifications

Knowledge of Medical Records and/or Health Information Technology

Education/Experience

Education:

High School Diploma or GED equivalent

Work Experience:

2 years in healthcare revenue cycle/medical records positions or an Associate’s Degree and no work experience.

Preferred Educational/Experience Requirements:

Associates Degree in related discipline

Preferred Licensure/Certification:

RHIT;

Associates degree in related discipline

Conditions of Employment

Must pass a pre-employment criminal background check, reference checks and a post offer drug screen.

Must be employment eligible as verified by the U.S. Dept. of Health and Human Services Office of Inspector General (OIG) and the Government Services Administration (GSA).

Tuberculin Skin Test required annually

Hospital required vaccinations

Hospital required competencies

Working Conditions

Typical office and/or patient care, acute care hospital environment.

Must be able to travel locally between facilities and within the surrounding community.

Occasional exposure to minimal physical risk

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Company info

Sandoval Regional Medical Center