Position Purpose:Accurately processes medical records, including document capture; identifies documentation deficiencies for physicians in accordance with Federal, State, Hospital and Accrediting Body requirements; prepares documents for disclosure in accordance with Federal HIPAA, State and Hospital regulations and policies; Completes documents for State vital statistics within the State prescribed timeframes.Routinely interacts with the public and physicians.
Essential Job Functions:
1.Scanning: On a daily basis, facilitates the use of the EHR by capturing paper documentation, properly preparing the paper for scanning, scanning, and indexing documents within 1 hour of receipt. Is able to distinguish document types, operate the scanning unit effectively, and scan all documents to the appropriate patient records and to the appropriate documentation type location with 100% accuracy.Performs QA on scanning done by others, identifies errors by clinical staff, and addresses errors with the clinical staff.Trains staff on proper scanning and indexing of documents.
2.Release of Information: On a daily basis, may interact with providers, clinical staff, and the public (patients, insurers, attorneys, State and Federal agencies, etc.) to accommodate requests for copies of patient information. Understands the release of information policies and associated Federal, State, and Hospital policies.Assists with release of information periodically or when on weekend rotation.Obtains appropriate release request document and verifies patient identity prior to release. Refers Amendment and Restriction requests to Director. Accurately logs releases in CIOX's or hospital accounting of disclosures/logging system.Efficiently prepares copies of requested in paper, CD, PDF, Fax and other approved electronic formats. Accommodates patient and physician requests within same day. Ensures only the minimum necessary is disclosed in accordance with HIPAA requirements. May handle release of information requests for the Shaw Regional Cancer Center. Does not routinely handle more than 30% of the Department's monthly requests.
3.Clinical Pertinence/Data Collection:Throughout the month, performs clinical pertinence reviews (for example, H&P timeliness, Operative Note/Immediate Post-op Note, and Transcription Blank reviews) for Accreditation purposes.
4.Work Queues: On a daily basis, reviews and rectifies those HIM Department work assignment queues, such as PT/OT, ED to Bed, CC copies, etc.
5.Other Projects:May work on special projects as required, including, but not limited to monthly Fax Number verification, tracking expenses, etc.
6.Schedule: Accommodates a varied work schedule including weekend coverage, especially during Season, to accommodate the work requirements of the Department and patient needs.
7.Customer Interaction: Effectively diffuses angry or unhappy customers.
8.Organization Culture: Supports the philosophy, objectives, and goals of VVMC and the HIM department. Role models the principles of a Just Culture and positively collaborates with team members to ensure the Department is functioning at optimal performance at all times by willingly assisting others in various capacities to complete the Department's work and without compromising one's own work expectations.
9.Compliance: Complies with all Hospital policies including, but not limited to the Compliance Program and Safety Program.Abides by standards of professional ethical conduct.Attends all required in-services and completes ELearning assignments.Identifies and attends training and educational programs conducive to professional growth. Utilizes current literature and educational sessions attended to the benefit of VVMC and shares new ideas, policies, regulations and other findings with peers and supervisors.
10.Other:Performs other duties as required.
This description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
§Successfully completed a course in medical terminology or anatomy, required.
§Excellent written and oral communication skills and the ability to work independently with minimal supervision, required. Legible penmanship required.
§Must have working-level knowledge of the English language, including reading, writing and fluently speaking English. Bi-lingual skills, preferred.
§High school graduate or GED equivalent, required. Some college coursework, preferred.Graduate from accredited school of Health Information Technology or Management, highly preferred.College graduate or certificate in other health related degree or certification, preferred.
§Office related experience of no less than 1 year, required.Experience in healthcare, preferred.Scanning and/or release of information experience, preferred.
§Experience working with the public in a customer service role, highly preferred.
§Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Licensed Practical Nurse (LPN), Registered Nurse (RN), or Certified Medical Assistant (CMA) preferred.
§Medical Billing or Coding Certificate, preferred.
Computer / Typing:
§Use of a computer, keyboard, and mouse and experience with basic Microsoft Office applications, required.Must possess the computer skills necessary to complete work assignments, online learning requirements for job specific competencies, access online forms and policies, complete online benefits enrollment, etc.Must have typing skills of no less than 20 WPM for this position.
§Ability to search resources and/or Internet to locate physician and healthcare facility information to make appropriate decisions.