Job Profile Summary Role:
The Health Information Management (HIM) Technician is responsible for organizing and updating information in the EMR and supporting
software systems. Performs data analysis and auditing to assist clinical management and administrative teams with documentation
improvement initiatives. Maintains the accuracy, completeness, and maintenance of medical records in accordance with the Organization’s
established policies and procedure.
Qualifications:
Associate’s degree in Health Information Technology or 5 years of work experience in Health Information Management
Services (HIMS) Department

• RHIT eligible preferred
• Experience using Electronic Medical Records (EMR), and Microsoft Office computer applications
• Ability to read detailed patient information reports, and transfer information into electronic records systems
• Ability to assess and deliver patient information, while maintaining accuracy to ensure quality patient care
• Excellent organization, time management, people and communication (written and verbal) skills; detailed oriented
• Ability to work independently with limited supervision, exercising some discretion and independent judgment
• Ability to bend, reach overhead, lift and move/transport multiple charts

Competencies:

• Satisfactorily complete competency requirements for this position.

Responsibilities of all employees:

• Represent the Company professionally at all times through care delivered and/or services provided to all clients.
• Comply with all State, federal and local government regulations, maintaining a strong position against fraud and abuse.
• Comply with Company policies, procedures and standard practices.
• Observe the Company's health, safety and security practices.

Job Description

• Maintain the confidentiality of patients, families, colleagues and other sensitive situations within the Company.
• Use resources in a fiscally responsible manner.
• Promote the Company through participation in community and professional organizations.
• Participate proactively in improving performance at the organizational, departmental and individual levels.
• Improve own professional knowledge and skill level.
• Advance electronic media skills.
• Support Company research and educational activities.
• Share expertise with co-workers both formally and informally.
• Participate in Quality Assessment Performance Improvement activities as appropriate for the position.

Job Responsibilities:
Gathers, analyzes, and audits all admission documentation submitted either in hardcopy or electronic format within 24 hours
of receipt, identifying and escalating all documentation deficiencies within 24-48 hours in accordance with the Organization’s
established policies and procedures.

• Identifies chart elements to determine if charts are complete and collects any missing documentation in a timely manner.

Documents, tracks, and escalates all deficiencies using the EMR and supporting software systems.

• Submits all unsigned documentation for timely signature; scans to the EMR, and/or routes documentation to appropriate team

for delivery to patient’s home.

• Completes scanning of the medical record documents after verifying all documents are completed in entirety per policy and

procedure.

• Requests prior medical records from hospitals and community care partners as needed.
• Runs and utilizes reports within the EMR to identify admission, discharges, and chart deficiencies.

Functions as a super user for all systems used by HIM, and assists in training and supporting new HIM staff in the acclimation
of the HIMS Department as well as the Organization.

• Performs concurrent and retrospective medical record audits to identify, track and escalate documentation deficiencies for

completion.

• Processes Release of Information requests in compliance with Federal and state laws as well as established organizational

policy and procedure.

• Abstraction, verification, submission and validation of patient data to Medicare Administrator Contractor and CMS, as

required, based on the Organization’s policy and procedure.

• Performs other duties as assigned.