Director Emergency and Trauma Services - Registered Nurse

Health Information Management Specialist

Kaweah Health is a publicly owned, community healthcare organization that provides comprehensive health services to the greater Visalia area in central California. With more than 5,000 employees, Kaweah Health provides state-of-the-art medicine and high-quality preventive services in our acute care hospital, specialized health centers and clinics. Our eight-campus healthcare district has 613 beds and offers comprehensive health services across a broad continuum of care.

It takes a special person to work for Kaweah Health. We serve a region where the needs are great, which makes the rewards even greater. Every day, we care for people facing unique challenges and in need of healing. Throughout it all, our focus is to make a difference, and we do in the health of our patients, our loved ones, and our community.

Benefits Eligible

Full-Time Benefit Eligible

Work Shift

Day - 8 Hour or less Shift (United States of America)

Department

8700 Health Information Management

Responsible for ensuring medical records are complete, and all documents are properly identified and signed, and that all necessary information is in the electronic health record. Releases health information, ensures the integrity of the medical record, and provides access to health information to patients and healthcare providers.

Qualifications

License/Certification Preferred: Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA)

Education Required: High school diploma/GED equivalent

Preferred: Two years of college or formal health information technician training.

Medical terminology course completion.

Experience Required: One year Health Information Management Department or medical related experience involving use of computers and familiarity with medical record forms.

Customer service experience.

Preferred: Medical record deficiency analysis and release of information experience.

Knowledge/Skills/Abilities

Knowledge of medical record practices. Familiarity with the components of a medical record. Knowledge of medical terminology. Excellent customer service skills. Computer/keyboarding skills and working knowledge of office equipment operations. Ability to use Microsoft Outlook, Excel and Word and have basic computer operational knowledge. Highly organized and detail oriented. Knowledge of HIPAA regulations preferred.

Job Responsibilities

Essential Utilizes the hospital information system Master Patient Index (MPI) to confirm patient data assuring accuracy of patient data.

Navigates Electronic Health Records Software efficiently.

Ability to perform document preparation, scanning and quality control to convert paper documents into electronic images.

Maintains the accuracy and integrity of the patient's medical record.

Keeps equipment secure and safe at all times.

Performs routine maintenance to ensure equipment functions properly.

Locates, retrieves, prints and/or faxes/e-mails medical records for continuity of care purposes.

Attends and participates in meetings.

Maintains confidentiality and security of patient healthcare information.

Answers telephones promptly and courteously.

Handles inquires appropriately.

Communicates effectively with patients, customers, physicians, and other departments.

Fax Queues and Folders

Maintains and monitors designated queues in Work Queue Monitor (WQM) fax queue.

Processes documents in the Work Queue Monitor (WQM) fax queue within one (1) business day of receipt.

Processes EHR determination notices within one (1) business day of receipt.

Release of Information

Serves as the receptionist for the department, answers phones, greets and assists people.

Provides high quality customer services in accordance with Kaweah Health's Mission.

Handles multiple priorities with frequent interruptions.

Processes all release of medical record information in a timely manner in accordance with regulatory compliance guidelines.

Prioritizes release of information requests.

STAT requests are prioritized based on the need for Continuum of Care, order received, otherwise processed no later than end of business day.

Handles all requests and inquiries for patient health information whether received via mail, HXE, fax, phone or in person.

Verifies identity and confirms that the authorization is valid.

Ensures the requesting party has a legal right to request a patient's medical information.

Responds to and fulfills requests from patients, third party payors, auditors, providers, compliance, etc.

Ensures all release requests are HIPAA compliant and verifies all releases for accuracy.

Communicates with requesters regarding the request process and also the validity/completeness of submitted authorization.

Receives all correspondence and subpoenas requesting patient specific information.

Correspondence shall be worked daily with subpoenas answered within 3-5 business days.

Facilitates Accounting of Disclosure requests and Requests for Amendments according to HIPAA Privacy Policies.

Serves as liaison with outsource company representatives to ensure processing of requests within required guidelines.

Maintains current knowledge related to applicable statutes, regulations, and standards necessary to perform the job.

Chart Deficiency Analysis

Reviews inpatient and outpatient medical records for completion, accuracy, and compliance with regulations.

Enters chart deficiencies into the computerized system for each incomplete or missing document.

Updates deficiencies and completed documentation as necessary no later than five (5) days from patient discharge.

Monitors and clears on hold tasks and the reanalysis queue daily.

Maintains and monitors report of charts pending physician completion.

Notifies responsible physicians and medical staff of record delinquency.

Serves as a resource and liaison for physician issues or questions in the completion of records, dictated reports or reports created in the electronic health record so as to affect a smooth work flow.

Regularly communicates with physicians and other health care professionals to obtain incomplete documentation.

Maintains knowledge related to documentation requirements necessary to perform job.

Reviews the Refused Verbal Order report on a weekly basis and re-assigns orders to the appropriate party.

Data Integrity

Identifies and corrects duplicate medical record and guarantor numbers.

Utilizes reports from the Soarian Financials System which identifies numbers that have been assigned in error.

Identifies and corrects duplicate guarantors within the medical record.

Transfers scanned documents in medical records that have been changed from outpatient to inpatients or other status changes to ensure only one complete record.

Reviews request to remove erroneous documentation and delete if found to be a valid request.

Creates Home Health accounts with information provided from admit list report.

Reviews loose Home Health Documents in attempts to identify corresponding encounter, episode number and/or create account/MRN if one not found.

Patient Portal

Serves as the subject matter expert on patient portal functionality.

Assists patients who are not able to establish portal access through self-registration by sending them an invitation to MyHealth Portal.

Interacts with patients and patient representatives to establish proxy access.

Assures that appropriate consent is obtained prior to establishing proxy access.

Serves as the primary Kaweah Health contact for MyHealth Portal.

Answers calls in prompt and professional manner.

Responds to email and voicemail requests in a timely and efficient manner.

Vital Statistics

Serves as a liaison and main point of contact for funeral homes and physicians to coordinate the completion of death certificates.

Runs a daily census and identifies patients who have expired in the medical center in order to begin the death certificate process.

If contacted by a funeral home, initiates the death certificate process in not already identified via the census.

Identifies the physician responsible for providing causes of death and completion of death certificate.

Issues attestations to physicians in a timely manner.

Follows up as needed to assure the causes of death are provided timely.

Follows up with appropriate parties as needed when causes of death are rejected by the county.

Uses the California Electronic Death Registration System (EDRS) to enter causes of death for the death certificate.

Maintains and tracks the death certificate process from beginning point until the death certificate is finalized.