Health Information Specialist I

Health First Medical Records Specialist

To be fully engaged in providing Quality/No Harm, Customer Service and Stewardship by maintaining accurate and complete medical records for each patient treated at Health First, assuring that the confidentiality, security, and integrity of the data and information is maintained, and providing complete and timely use of data and information, without compromising security and confidentiality. Responsibilities may vary based on job role within the department.

Quality/No Harm:

• Demonstrates competence in the computer applications necessary to carry out work responsibilities.
• Proficiently navigates through the computer applications in order to identify patient by name, account number, medical record number or date of service and ability to locate appropriate chart based on that information and verify accuracy of demographic area.
• Proficiently navigates through Microsoft Office applications to include: Word, Excel, and PowerPoint.
• Maintain and observe confidentiality, security, and integrity of all personal health information as required in Joint Commission standards and HIPAA guidelines.
• Appropriately reviews charts for accuracy and completion and reassigns to the appropriate designated queue for follow up on any potential problems.
• Performs routine monitoring and/or validation of COLD documents in patient charts.
• Request COLD resends from appropriate IT Analysts to ensure the accuracy and completeness of all patient records.
• Birth Certificates are processed within 24 hours of receipt in order to maintain the 90% (or above) compliance rate mandated by the state for birth certificates to be filed within the 5-day time frame with no more than 5 errors per year.
• Performs Adjust Document Index function to include correctly inserting, splitting, moving, and appending pages/documents when and where appropriate at least 98% of the time.
• Charts are accurately analyzed according to Joint Commission requirements and Medical Staff Bylaws and Rules and Regulations, correctly identifying missing elements and assigning deficiencies to the appropriate physician at least 98% of the time.
• Maintains analysis turnaround within required time frame at least 98% of the time Writes scanned and indexed batches to the appropriate queue according to departmental policy and procedure at least 98% of the time.
• Assists with chart completion process by identifying physicians needing to complete charts, generates physician notification letters according to specified policy, communication with physician offices regarding chart completion/suspension. Maintaining appropriate documentation regarding physician communication and physician privileges/suspension.
• Processing audits/chart requests for release including validation of completeness and preparations to ship records to appropriate requestor.

Stewardship:

• Takes initiative to take on additional assignments or changes in scheduling based on daily observations in a willing manner.
• Understands and supports the processing of reports and charts according to department turn-around-time goals.
• Oversee the post discharge physician query process, processing and scanning the queries into the medical record within 24 hours of receipt.
• Reviews assigned work queue(s) daily and ensures timely processing of assignments in the queues.
• Productivity standards are met according to departmental policy and procedure for each job function on a weekly basis.
• Analyze the contents/documentation in the medical record to capture and assist with the accurate abstracting of all appropriate data fields ensuring accuracy and completeness.

Customer Experience:

• Provide patient information to appropriate requesters in a timely and efficient manner.
• Understands the confidentiality of patient information and proper dissemination of this information.
• Adheres to all Health First policies and procedures in regards to protected health information.
• Consults with management to clarify any concerns.
• Provides professional and courteous communication to all customers at all times.
• Communicate with physicians offices regarding documentation concerns for post-discharge queries as necessary.
• Respond to coding issues/concerns from Health First departments as necessary to clarify coding related issues.
• Always displays professionalism and respect, every person, every time.
• Completing birth certificates in a professional and courteous manner. Appropriate screening of all newborns for statistical reporting to the state of Florida. Familiar with all forms and brochures used in the birth certificate process.
• Responsible for responding to Risk Management chart requests and appropriately assigning charts to the Risk Management queues.
• Verifies physician dictation on the dictation system when analyzing and assigning deficiencies that are not in HPF/chart at least 98% of the time Provides report of newborn names to Data Integrity Analyst within appropriate timeframes.

Qualifications Required:

• High school graduate required.
• A.S. or higher level degree preferred or 3+ years HIM/healthcare related experience.
• RHIT preferred.
• Understanding of Joint Commission standards, State regulations, HIPAA, CMS and medical staff rules and regulation requirements preferred.

Physical Demands:

• Visual Acuity to include viewing PC monitor for extended amount of time.
• Ability to enter data and prep charts using hand/wrist dexterity.
• Ability to sit at a computer for extended periods of time.
• Able to appropriately transport 25 pounds of medical records.
• Ability to sit, walk or stand for extended periods of time.
• Ability to bend and stoop.
• Ability to travel to all facilities/campuses across the IDN.

Mental Demands:

• Ability to read and comprehend instructions, correspondence, memos, and electronic mail.
• Must be detail and accuracy oriented.
• Ability to coordinate and use logical reasoning to facilitate daily workflow assignments.
• Ability to work independently, maintaining focus on scope of work assigned.
• Is self-sufficient, not needing to rely on others to complete a job.
• Initiative independently takes prompt proactive steps toward problem resolution.
• Analytical skills effective evaluation, synthesis, and use of information gathered.
• Strong computer literacy and ability to enter and retrieve data from electronic systems.
• Strong written and verbal communication skills for professional interaction.
• Ability to prioritize tasks, coordinate and manage multiple tasks simultaneously.
• Must be able to work under potentially stressful situations with time constraints.
• Ability to use critical thinking and problem solving skills to carry out all job functions and responsibilities.
• Emotional intelligence recognize and understand emotions and use this awareness to successfully manage yourself and your relationships with others.

About Health First:

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.

Schedule: Part-Time

Shift Times: 800am430pm

Paygrade: PG-26