Position Summary: Under the direction of the Manager of Release of Information, this position is responsible for abstracting, processing and/or preparing medical record requests including but not limited to court orders, subpoenas, attorney requests, patient requests, continuity of care requests and other authorized parties; in accordance with HITECH, HIPAA Regulatory Guidelines, Massachusetts General Laws, Federal Public Health Laws, CURES Act (Information Blocking) and hospital/department policies and procedures.The Release of Information Associate will ensure a timely response to requests and maintain the confidentiality and integrity of all information. 

Major Responsibilities:

1. Responsible for the receipt of valid subpoenas, and authorized judicial Court Orders, Search Warrants, and Summons, based on hospital policy and procedure. Requests court orders as required by law to release specifically protected or privileged information. Interacts with attorneys and court representatives for clarification on requests as needed. 
2. Provides certification of true and complete medical records. Testifies at Grand Jury Hearing, Court Trials, and attorney offices as to the authenticity of said health records containing PHI.
3. Responsible for the review and release of Protected Health Information (PHI) to the Department of Children and Families (DCF) and other authorized parties or legal entities in compliance with HITECH, HIPAA, General Laws of the Commonwealth of Massachusetts (MGL), Department of Public Health (DPH), and the policies of UMass Memorial Health. 
4. Accurately abstracts and or prepare records by screening and analyzing health records for any protected or privileged information that is not covered under a general authorization. When required, obtains proper authorization for records containing treatment of alcohol and drug abuse, sexual transmitted disease, genetic screening results, licensed social worker, mental health, domestic violence counseling, substance abuse (42 CFR Part 2) counseling and sexual assault counseling as defined by the state and federal law, specifically stating the type of information that is being released. 
5. Certify authorization form is HIPAA-compliant, determine when medical records can be released, or an exception is needed. Ability to identify protected health information and determine what to redact (manually and/or electronically) based on regulatory requirements.
6. Protects the patient’s right to privacy by ensuring that only authorized individuals have access to the patient’s medical information and that all releases of information are in compliance with the request, authorization, HIPAA and Massachusetts state regulations.
7. Forwards non-HIM requests to appropriate area(s) within the institution as needed. (e.g.: Risk Management, Central Billing Office, Human Resources, etc.) 
8. Maintains a working knowledge of medical terminology to ensure the ability to review and release medical records as appropriate. Understand when it is necessary to review records with physicians for approval. 
9. Maintains a working knowledge of the faxing workflow application and utilizes functionality to index faxed/ scanned imaged of authorizations and to access assigned authorizations from work queues to fulfill requests. 
10. Enters/scans/uploads all requests into the EMR in an effort to log, triage and track requests for retrieval purposes. Utilizes applicable legacy systems to retrieve PHI as needed.
11. Initiates callbacks to all telephone communications within 24-48 business hours or immediate callbacks for any STAT/Urgent medical record needs. 
12. Completes all processing for a variety of request types including but not limited to Patient requests, STAT requests, Insurance requests, Appeals/Billing Requests, etc. 
13. Receives Audit Requests, validates Confidentiality Form and contact information is on file, works with Information Management Systems (IM/IS) to establish access in Epic, as needed to review the requested records, prepares records for their access and notifies Auditor of their access information. Acts as the departmental liaison for questions regarding audits. 
14. Performs quality checks on all work to assure accuracy of the release, confidentiality, and proper invoicing.
15. Knowledge of the fee structure and ability to invoice and process payments for multiple request types. Ability to reconcile payments received. 
16. Must understand all delivery methods and must be able to utilize as appropriate (Email, fax, My Chart, Epic Care Link, Chart Gateway, multiple vendor portals, etc.).
17. Maintains up-to-date knowledge of the location/entity of medical records. Orders records from the off-site location, when necessary. 
18. Maintains equipment in excellent operating condition and troubleshoot equipment issues with assistance from the Help Desk department.
19. Provides excellent customer service by being attentive, respectful, and professional at all times; ensures understanding of customer request and follows-through as promised; being proactive in identifying and addressing concerns, or problems.
20. May be assigned special projects and other related duties based on the demands of the workflow and as defined by the supervisor or manager.

Standard Staffing Level Responsibilities:

1. Complies with established departmental policies, procedures and objectives.
2. Attends variety of meetings, conferences, seminars as required or directed.
3. Demonstrates use of Quality Improvement in daily operations.
4. Complies with all health and safety regulations and requirements.
5. Respects diverse views and approaches, demonstrates Standards of Respect, and contributes to creating and maintaining an environment of professionalism, tolerance, civility and acceptance toward all employees, patients, and visitors.
6. Maintains, regular, reliable, and predictable attendance.
7. Performs other similar and related duties as required or directed.
8. Maintains a neat, clean, and professional personal appearance and observes the dress code established by the Company or department.

All responsibilities are essential job functions.

Position Qualifications:

License/Certification/Education:

• Required: High School Diploma or equivalent
• Preferred:
  • Associates degree, current or eligible accreditation by the American Health Information Management Association (AHIMA), Registered Health Information Technician, Administrator (RHIT/RHIA) and/or related degree.
  • Knowledge of medical record and release of information procedures, at a level generally acquired during 3 – 5 years’ experience.
  • Comprehensive understanding of the components of a medical record, including how a record is maintained, organized and the retrieval of medical documentation in both paper and/or electronic format.

Experience/Skills:

• Required:
  • Must have mastered all responsibilities of the ROI Associate Level 1
  • Three (3) or more years of healthcare experience. Preferably in a Health Information Management Department.
  • Training in medical and legal terminology
  • Computer-literate and proficient with Microsoft Windows applications. 
  • Ability to analyze data when operating within multiple systems.
  • Excellent customer service skills with the ability to communicate efficiently.
  • Exceptional organizational skills with attention to detail.
  • Ability to problem-solve, organize, and prioritize workload to meet Turn-Around-Time (TAT) benchmarks. 
  • Knowledge of HITECH, HIPAA, General Laws of the Commonwealth of Massachusetts (MGL), Cures Act (Information Blocking), Department of Public Health (DPH), etc. 
  • Ability to withstand significant level of ongoing pressure, and ability to deal with individuals with tact, discretion and diplomacy.

Unless certification, licensure or registration is required, an equivalent combination of education and experience which provides proficiency in the areas of responsibility listed in this description may be substituted for the above requirements.

Department-specific competencies and their measurements will be developed and maintained in the individual departments. The competencies will be maintained and attached to the departmental job description. Responsible managers will review competencies with position incumbents.