Health Information Specialist

Montgomery County Emergency Service (MCES), is a Joint Commission accredited Inpatient Psychiatric Hospital. The Health Information Technician (HIT) is an in-person position, which manages, organizes, and secures patient medical data in electronic health record (EHR) systems. The HIT ensures medical records are organized and maintained in both paper files and electronic systems within the Health Information department. The HIT enters seclusion & restraint and other medical record data into the HBIPS portal, assembles discharged patient charts, conducts follow-up calls to outpatient providers for individuals discharged with a co-occurring diagnosis, and serves as a backup to the Administrative Assistant, in their absence.

Responsibilities

• Accurately generates and completes discharge summaries, enters seclusion & restraint and other medical record data into the HBIPS portal, assembles discharged patient charts, conducts follow-up calls to outpatient providers for individuals discharged with a co-occurring diagnosis, and serves as a backup to the Administrative Assistant, in their absence.
• Maintains an accurate tracking system of all discharge summaries, consults with Medical Staff regarding outstanding discharge summaries and information needed to complete the discharge summaries, and files/scans completed discharge summaries and removes from the Access database.
• Conducts chart reviews to assure that all appropriate documentation is included in the medical record and that the content is complete and accurate, has sufficient detail to reflect the treatment and services provided, the patient’s course through treatment, the goals of treatment, and to support billing and coding functions.
• Assists with creating, organizing and maintaining patient medical record system for the hospital in accordance with the policies of the hospital as well as The Joint Commission (TJC), Department of Drug and Alcohol Programs (DDAP), Department of Health (DOH), Office of Mental Health and Substance Abuse Services (OMHSAS), State and Federal law and other regulatory agencies.
• Maintains knowledge of current healthcare privacy laws, health information regulations, industry best practices, as well as patient confidentiality and patient privacy in accordance with regulatory agencies.

Qualifications

• High School Diploma or equivalent required, Degree preferred. A minimum of three (3) years of specialized experience and/or training in medical records within a hospital or healthcare setting preferred. Will consider any combination of experience, education or training that would provide the level of knowledge, skill and ability required.
• Proficiency in using EHR systems, EMR/EHR management tools, and Microsoft Office applications for documentation and reporting purposes. Experience with both electronic and paper charting required.
• Knowledgeable of healthcare privacy protection laws, health regulation policies, clinical confidentiality standards, and medical terminology.
• Excellent organizational skills, effective communication and collaboration skills, with the ability to work well with others.
• Prior experience in medical office settings or healthcare facilities is highly desirable.

WE ARE AN EQUAL-OPPORTUNITY EMPLOYER (M/F/Veteran/Disabled). MCES prohibits harassment and does not discriminate based on race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.