Non-Clinical - Health and Information Management - Health Information Services Technician

Health Information Tech I

This position processes health information under the direction of the HIM Director or designated supervisor. This position is responsible for coordinating physician medical record completion and the quantitative analysis of all medical record patient types based upon standards established by Title 22, CIHQ, Conditions of Participation and the Medical Staff Rules and Regulations.

Specific skills needed:

• Medical Record documents
• Physician chart completion and chart deficiency analysis
• Basic keyboarding skills
• Knowledge of medical terminology and familiarity with computers
• Typing speed of 35 wpm
• Ability to categorize forms/documents within the medical record
• Detailed oriented, self-motivated
• Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements
• Ability to concentrate and maintain accuracy despite frequent interruptions
• Ability to be courteous, tactful, and cooperative throughout the workday
• Ability to use standard office equipment including computers, photocopy, facsimile (FAX) and scanners
• Knowledge of Title 22, CIHQ, Conditions of Participation, Medical Staff Bylaws and Medical Staff Rules and Regulations

Education/Experience/Training:

• Knowledgeable of Windows Software
• 3-5 years of Medical Record experience in an acute care setting
• Previous experience with electronic health record applications
• High School graduate or equivalent
• Knowledge of physician record completion and HIPAA
• Knowledge of medical terminology

Duties and Responsibilities:

1. Safeguards and preserves the confidentiality of patient's protected health information in accordance with State and Federal (HIPAA) regulatory requirements, hospital, and departmental policies.
2. Ensures a safe patient environment and adherence to safety practices per policy.
3. With consideration to age, employee utilizes the approved process to resolve biophysical, psychological, educational, and environmental needs of patient/significant other when administering care.
4. Notifies physicians of medical records requiring their completion in accordance with Medical Staff Bylaws, Rules and Regulations, Title 22, and Center for Improvement in Healthcare Quality (CIHQ) and all other applicable regulatory agencies. Maintains documentation of the notifications.
5. Administers all medical staff guidelines as it pertains to the medical record completion, uniformly and consistently among all members of the medical staff. May perform daily counts of number of records pending completion using the computer-generated reports. Monitors unsigned and refused electronic orders, tasks, and documents.
6. Retrieves incomplete records and/or assists physicians on a one-to-one basis in completing their records electronically.
7. Activates temporary suspension of medical staff privileges when records are not completed in a timely manner. Communicates suspension information to other departments per Health Information Management Department procedures. Maintains documentation of days on suspension to fulfill mandated reporting requirements and Medical Staff reappointment/credentialing needs.
8. Analyzes and re-analyzes incomplete paper and electronic medical records to assure the completeness of information. Updates chart tracking system to reflect the current status of the incomplete record.
9. Scans loose filing into the ChartMaxx System.
10. Utilizes ChartMaxx to accomplish deficiency analysis and reporting.
11. Adheres to daily productivity standards provided in separate documentation.
12. Oversees all incomplete medical record activities and functions.
13. Assists physicians with record completion issues and escalates them if resolution cannot be achieved in a timely manner.
14. Completes a RLDatix Incident Report for any potential compensable event identified during the record review or completion process.
15. Conducts record review function with established criteria and provides data to Director or designated supervisor.
16. Able to perform basic eScription1 monitoring, pending and look up functions
17. Operates the office equipment normally used in the routines of daily work, such as photocopy machine, facsimile (FAX) equipment, computers, scanners, and telephones.
18. Must be able to communicate effectively with all ages of customers served.
19. Abiding by and strongly enforcing all compliance requirements and policies and performing his/her responsibilities in an ethical manner consistent with the organization's values.

Teamwork/Customer Service Responsibilities:

• Customer Service Values and Behaviors:
• Value: Each person is treated with respect, dignity, fairness, and compassion. Behavior: Performance is acceptable when everyone is promptly greeted with a smile in a warm and caring manner using the person's name whenever possible. No matter how I feel, I display a caring attitude.
• Value: Each person displays loyalty and pride in PIH Health and upholds the confidentiality of patients, visitors, physicians, and co-workers. Behavior: Performance is acceptable when concerns/problems with fellow employees and customers are not discussed with anyone other than the person involved or the supervisor. Customer issues and ideas are listened to and appropriate follow up occurs to create a satisfied customer. I do not make excuses. I do not demean other people or departments.
• Value: Each person demonstrates commitment to open communication. Behavior: Performance is acceptable when openness and acceptance of constructive criticism occurs. Positive communication occurs by complimenting and expressing appreciation to others. I will listen and encourage others to express ideas and opinions.
• Value: Each person demonstrates pride in the physical appearance of all PIH Health properties. Behavior: Performance is acceptable when the initiative is taken to maintain a clean and safe environment. I conduct myself in a manner which respects and preserves equipment and the physical plant. I do not walk by spills, trash, or unsafe conditions without assuring that they are attended to promptly by me or appropriate personnel.