Overview

POSITION SUMMARY:

Under the direct supervision of the Health Information Management Manager, supports the JHHS clinical operations by carrying out all duties and responsibilities, policies, and procedures that contribute to efficient medical records operations. Duties include scanning, classification, storage, archival, and retrieval of medical records. Follows HIPAA guidelines, Privacy Act and other applicable confidentiality standards; uphold highest standards of privacy and confidentiality.

Responsibilities

ESSENTIAL FUNCTIONS:

• Policies and Procedures- Maintain established departmental policies and procedures, objectives, and quality assurance programs.
• Provides record imaging services; act as a contact point for document imaging software applications and issues, including scanning, control and retrieval.
• Review information contained in documentation to ensure it is in an approved format.
• Provide daily chart analysis of all medical records for inpatient, day surgery, and observation discharges, to ensure The Joint Commission (TJC) accreditation.
• Review H&P, Operative Reports and Discharge Summaries to ensure they meet CMS documentation requirements. Assign provider deficiencies when appropriate documents are missing or not authenticated per medical staff rules, regulations and department guidelines.
• Maintain medical record confidentiality and legal requirements. Documents and logs medical records requests.
• Scans current and archived documents; performs image manipulation as required by the limits of the imaging system.
• Maintains document storage databases using specialized imaging software applications and equipment.
• Work as a team to identify process issues and report identified problems with document preparation, scanning, quality check, or validation, be technical or clerical staff.
• Creates proper note titles and entries in electronic medical records.
• Process all requests for information in accordance to federal, state, and regulator timeliness guidelines. Complete all reviews and documentation processing within established timeliness standards.
• Organizes, maintains and purges various departmental files; develops indexing systems; photocopies and microfilms information as required.
• Participates in the destruction of documents per policy and procedure.
• Assist in project planning, implementation and completion.
• Assists in training of new staff.
• Performs administrative duties; answers telephones; respond to inquiries from staff and the public regarding medical documents, searches for and provides information and copies of official documents; solve routine problems associated with locating records and documents.
• Create and maintain daily records of work performed.
• Perform miscellaneous job-related duties as assigned.
• Represents the Pueblo with dignity, integrity, and a spirit of cooperation in all relationships with staff and the public.
• Serves as a back up to patient registrars as needed; greets patients, staff, and visitors in a positive, helpful, and professional manner; interviews in-coming patients for medical and/or hospital care to obtain accurate demographic information.
• Verify insurance coverage for all patients and distribute consent forms. Researches missing information on intake forms; obtains signatures and release forms.

Qualifications

Education and Experience:

Associate’s degree in Health Information Technology (HIT) or related field; AND two (2) years of administrative/clerical experience in medical field; OR High School Diploma or GED equivalent and four (4) years of administrative /clerical experience in the medical field.

REQUIRED CERTIFICATES, LICENSES, AND REGISTRATIONS:

• Valid New Mexico Driver’s license.
• Registered Health Information Technician (RHIT).