Job Summary:

The Health Information Management Specialist is responsible for day to day processes regarding the establishment and maintenance of medical records in the Electronic Health Record (EHR). Manages the EMR for training and data entry. Ensures accuracy of information through review and Quality Improvement. Manages all release of information requests and requests necessary documentation, as needed. Manages all Health Information that is generated by the IDT and comes from outside sources; such as, labs, consultations, home care.

This position supports organizational goals by providing quality customer service, participating in performance improvement efforts and demonstrating a commitment to team work and cooperation

Essential Duties and Responsibilities:

1. Supports and assistance with the management an electronic health record for each participant, including scanning notes pertaining to outside consultations and reports from outside tests, procedures, or studies.

2. Responsible for assisting with maintenance of medical records within HIPAA standard and regulatory compliance, including organizing the storage, archiving, retrieval, and destruction of medical records.

3. Scans all required documents into the EHR.

4. Build and maintains participant emergency paper charts, if needed.

5. In conjunction with clinic staff, tracks external appointments and tests/procedures to ensure all follow up documentation has been received and scanned into the participant’s record

6. In conjunction with clinic staff, obtains all necessary documentation from hospitals, providers, and other health entities as needed to ensure quality of care for participants across the continuum.

7. In conjunction with clinic staff, obtains all needed documentation from emergency department, inpatient, and skilled nursing admissions. Scans documentation into the medical record.

8. Responsible for the documentation and release of medical records as requested. Abides by all confidentiality requirements as they relate to the release of protected health information.

9. Provides feedback on opportunities for improvement with EHR workflows and/or documentation procedures to maintain compliance with regulations.

10. Assists the Quality Management Coordinator with projects.

11. Participates in quality improvement activities including but not limited to medical record audits, competency training, and regulatory compliance.

12. Assists in the development and modification of policies and procedures related to medical record establishment and documentation, release of medical records, and privacy guidelines.

13. Attends morning meetings and committee meetings to take minutes as requested. Types and distributes minutes as requested.

14. Serves as an EMR Power User.

15. Demonstrates excellent organizational skills and ability to prioritize.

16. Refers problems to appropriate resources. Interfaces with and receives direction from Director of Quality, Compliance, & Education .

17. Reports to Director of Quality, Compliance, & Education .

General Responsibilities:

1. Must work the days and hours necessary to perform all assigned responsibilities and tasks. Must be available (especially during regular business hours or shifts) to communicate with supervisors, customers, vendors, and any other person or organization with whom interaction is required to accomplish work and employer goals.

2. Must be punctual and timely in meeting all requirements of performance, including but not limited to, attendance standards and work deadlines; beginning and ending assignments on time; and scheduled work breaks, where applicable.

3. Must maintain courteous, professional and effective working relationships with employees at all levels of the organization.

4. Must develop and maintain courteous and effective working relationships with clients, vendors and/or any other representatives of external organizations.

5. Must show respect for the opinions of others and behave in such a way as to ensure an atmosphere free of needless interruptions, difficulty and/or discrimination.

6. Must handle in a constructive, non-disruptive manner, the multiple business, organizational and interpersonal changes or stresses that may exist in the employee’s work, work processes, dealings with other personnel, and supervision (provided or received). (“Work processes” include but are not limited to, how work is performed, supervised or distributed; how problems are solved; and how decisions are made.)

7. Must be sufficiently adaptable to accept and perform, in a timely and effective manner, work assignments that are outside the normal (day-to-day) routine.

8. Must adapt, with minimal or no advance notice, to changes in how business is conducted and work is accomplished.

9. Performs related duties as required.

Qualifications:

1. Education:

a. Bachelor’s or Associates Degree in Health Information Management Program (RHIA/RHIT), preferred

b. High School Diploma or equivalent

2. Experience:

a. Familiarity with healthcare operations and healthcare terminology, including HIPAA and EHR functioning

b. One-year experience in a healthcare environment.

3. Age of Patients Rendered Care:

a. Adult and geriatric patients

*** Freedom from illegal use of drugs, and freedom from use and effects of use of drugs and alcohol in the workplace.

*** Persons who have been found guilty by a court of law of abusing, neglecting or mistreating individuals in a healthcare-related setting are ineligible for employment in this position.

Knowledge and Skills:

To perform the job successfully, an individual should demonstrate the following competencies:

1. Proficient in MS Office suite of applications, including Outlook, Word and Excel. Must be willing to learn other software programs utilized by the PACE Program.

2. Customer service skills.

3. Develops and maintains a working knowledge of program record keeping policies and procedures, and the ability to apply knowledge to job tasks.

4. Shows evidence of strong organizational, verbal, and written communication skills.

5. Sufficient interpersonal skills and maturity to communicate effectively with professional staff, direct care staff, consultants, visitors, and others, in person and on the telephone.

6. Ability to establish appropriate priorities for receiving, relaying and acting on information, and to maintain organization of all records.

7. Appreciates the importance of maintaining confidentiality of information.

8. Demonstrates honesty and integrity at all times in the care and use of program property.

9. Able to understand and to follow written and verbal directions. Able to effectively communicate through verbal and written means.

10. Develops and maintains knowledge of emergency and disaster procedures of the program. Able to locate nearest exit, and to understand and respond to written or oral instructions in case of an emergency.

11. Sufficient mobility and strength to move freely through the building and to maintain personal safety at all times.

12. Demonstrates respect for co-workers and responds to the needs of the program by complying with program policies on attendance and punctuality and dress code. Able to arrive and to begin work on time and to report for duty as scheduled on all shifts.

13. Demonstrates ability to prioritize tasks/responsibilities and complete duties/ projects within allotted time.

14. Able to respond to change productively and to handle additional tasks/projects as assigned.

15. Able to carry out the essential functions of this job (with or without reasonable accommodation) without posing specific, current risk of substantial harm to health and safety of self or others.

16. Ability to exchange information clearly and concisely with the supervisor, managers and co-workers.