HIM Tech I

Job Description

Job Description

Description:

Performs technical and clerical tasks utilizing knowledge of HIM Departmental and Cibola General Hospital policies and procedures as well as state and federal regulations mandating processing Birth Registry. Responsible for accurate scanning of paper-based medical records into the electronic medical record (EMR) and analyzes medical records for deficiencies. Notifies clinicians of their medical record deficiencies on a weekly basis. Provides coverage for release of information functions, including written and verbal requests for health information.

Essential Functions:

SCANNING/ANALYZING MEDICAL RECORDS

• Retrieves discharged inpatient, OPS and specific ancillary records/reports from Nursing Units/departments daily. (M-F)
• Reconciles records received against the HIM Admit/Discharge list in Cerner to ensure all charts are accounted for.
• Sets scanner to count the number of pages to be scanned
• Scans all incoming records on a daily basis.
• Checks quality of scanned report and ensures readability of the scanned reports.
• Correctly follows all steps of scanning program bringing any issues/problems to the immediate attention of the HIM Director or IT Support.
• Maintain charts that have been scanned for 30 days.
• Analyzes all discharged records daily to include tagging deficiencies and logging deficiencies into the computer tracking system.
• Process weekly deficiency communications to physicians/other clinicians per hospital policy.
• Remove and clear all completed deficiencies form computer tracking system and chart as is needed.
• Answers phones and assists with release of PHI as needed.
• Updates H&P, Operative Report and Important Message from Medicare logs daily.
• Completes expired index.

BIRTH REGISTRATION

• Obtain demographic information "Mothers Worksheet" to complete birth registration on each newborn.
• Fill out paternity paperwork as is needed according to State of New Mexico guidelines
• Enter information into computer system "DAVE" according to State of New Mexico guidelines for registration of births.
• Performs Notary Public duties according to New Mexico Law
• Maintain a monthly log of births to be utilized for hospital statistics.

RELEASE OF PROTECTED HEALTH INFORMATION (PHI)

• Retrieves mail daily from the mailroom
• Verifies that all required elements of an authorization are present per HIPAA requirements
• Utilizes Master Patient Index to obtain medical record numbers using EHR system to locate electronic health information
• Copies, faxes or emails protected health information (PHI)
• Knows/understands and follows Release of Information Policies and Procedures regarding the proper process to release health information
• Attends annual HIPAA training to stay current on all state and Federal Regulations pertaining to release of information
• Maintains computer entries for release of information, entering each field with correct information
• Processes and mails out requests and information requested within the time frame specified by request and/or type of request and/or according to HIPAA Privacy Rule
• Checks all copies made of medical records for quality and also verifies that information copied is accurate and has correct patient name/account number/medical record number
• Performs front desk receptionist duties by assisting all customers with requests and answering all department phone calls and fulfilling ROI requests
• Maintains microfilmed files
• Always utilizes a fax cover sheet when faxing and verifies that the phone number keyed is correct prior to selecting the send button and regular requestors must be programmed into the fax machine.
• Must meet all established quality and productivity standards at 95%.
• There are other duties, while not considered essential for this position, are required as part of the function of this position.

Education:

• High School diploma or equivalent required.
• Associate's degree preferred.