HIM Specialist II

• Accurately records telephone information and/or transfer calls correctly 100% of the time;
• Completes all task scheduled during the shift 100% of the time; and
• Advises supervisor of situations requiring follow-up attention.

2. Electronic Health Record Scanning
The Electronic Health Record Scanner serves as an intermediary to transfer and scan the paper health record into the electronic medical records.
PERFORMANCE STANDARDS:

• Performs scanning of the paper health information record into the electronic health record following the established guidelines;
• Performs qualitative and quantitative analysis of scanned document images to assure accuracy and legibility maintained;
• Participates with hospital office staff, and supervisors, hospital departmental staff and supervisors to establish well-coordinated compliant scanning routines;
• Serves as an educator and facilitator to assure timely record scanning and maintenance of hard copy health information records;
• Participates in the developing and updating of training materials;
• Promotes an atmosphere that encourages enthusiasm regarding accurate record maintenance and availability;
• Ability to operate and communicate effectively while under pressure;
• Maintain work schedule flexibility to meet short timeframes; and
• Demonstrates effective problem identification, problem solving and priority setting skills.

3. Document Specialist
PERFORMANCE STANDARDS:

• Maintain knowledge of Inpatient Rehab specific standards in accordance with each payor for accurate record keeping;
• Maintains an accurate hospital census each day, according to the Inpatient Rehab admit and discharge criteria/standards (i.e. 3-day hold); and
• Assists in record retention/destruction according to State Law.

4. Medical Record Analyst Responsible for collection, organizing, analyzing and reporting of healthcare/physician data.
PERFORMANCE STANDARDS:

• Identifies deficiencies in the medical record;
• Assists physicians with record completion; and
• Maintains an accurate record keeping of delinquent medical records.

5. Medical Record Statistics and Review
PERFORMANCE STANDARDS:

• Assists other departments (e.g. Risk Management, Quality, Nursing) in the review of Medical Record audits according to The Joint Commission/state standards;
• Reviews records to ensure compliance with Hospital Bylaws/Rules and Regs/The Joint Commission/state standards; and
• Assists in reporting hospital data/statistics to the appropriate departments for

Committees (e.g. MEC/Governing Body) review.
6. Performs multiple functions involving paper chart locating, recording, delivering, assembling, retrieving and filing of medical records as assigned.
PERFORMANCE STANDARDS:

• Demonstrates an ability to assemble and maintain records appropriately;
• Demonstrates a working knowledge of all medical record indices and computer systems as required for the accurate retrieval and location of patient records;
• Consistently coordinates work to achieve maximum productivity and efficiency during the assigned shift;
• Consistently demonstrates the ability to recognize, establish, and deal with priorities for multiple medical record assignments;
• Processes all assigned medical records for completion within one workday as assigned;
• Locates and retrieves incomplete records 100% of the time as requested;
• Accurately updates information on the computer for records as assigned;
• Files dictation with an accuracy rate of 100% as assigned; and
• Consistently assembles, analyzes, and reviews medical records of discharged patients to ensure compliance with departmental policy and regulatory requirements as assigned.

7. Functions as Lead Health Information Coordinator
PERFORMANCE STANDARDS:

• Maintains workload, individual proficiency, skill level, experience, speed, etc., to maintain efficiency and effectiveness of department in completing tasks;
• Monitors workflow, ensuring timely receipt and turnaround of charts within established parameters;
• Ensures work is completed correctly, according to departmental standards;
• Assist with Transcription (stat dictations assigned and completed);
• Work QA queues and holds in the dictation software; and
• Work failed fax queues and maintain accurate fax numbers for requested carbon copies (cc’s).

8. Performs designated functions including review of Requests for Release of
Information and Authorizations for Release of information (non-legal, disability, and walk-in requests). Determines the medical record numbers, account numbers and dates of service being requested by the requestor, and provides timely and accurate release of confidential patient medical information, accurate documentation and tracking of all requests for information, preparation of billing documents for requests
requiring payment, recording of payment received for billable requests, and providing personalized customer service to all requestors.
PERFORMANCE STANDARDS:

• Reviews all incoming requests for confidential information for validity according to applicable

state or federal statutes and hospital policies and procedures, regarding disclosure of confidential medical records information;

• Analyzes correspondence requests to determine what information is being requested;
• Returns inappropriate authorizations and requests to the requestor with a letter explaining the reason for denial of the request;
• Prepares incoming correspondence (non-legal and disability) for processing, including opening and stamping mail, and entering appropriate data into computerized release of information log;
• Provides other departments (e.g. Patient Financial Services, Medical Outreach Advocate, and Legal Departments) with requested confidential medical information as requested;
• Contacts other departments (e.g. Outpatient Rehab) for requested records;
• Maintains assigned release of information files and records on an ongoing basis;
• Copies appropriate portions of medical records (i.e. minimum necessary);
• Copies records as requested for Recovery Audit Contractors (RAC) and other reviews;
• Reviews and copies subpoenaed records;
• Prepares copies of medical records for certification;
• Prepares records for mailing;
• Prepares and documents invoicing for requests requiring payment;
• Follows established procedures for collection and handling of payments received;
• Assists walk-ins with requests for medical records;
• Coordinates the preparation of certified copies of itemized bills;
• Copies medical records of patients who are being transferred to another unit or hospital;
• Completes all tasks scheduled during the shift 100% of the time; and
• Advises supervisor of situations requiring attention.

9. Performs all other duties as assigned.

EXPERIENCE REQUIREMENTS
One year of experience preferred.
EDUCATIONAL REQUIREMENTS
High school diploma or GED preferred.
SPECIAL SKILL, LICENSE AND KNOWLEDGE REQUIREMENT
Knowledge of inventory control, computerized inventory procedures and medical/surgical supplies preferred. Must be capable of lifting up to 70 lbs. without assistance.