Statement of Purpose

Accurately enters data into the computer. Accurately preps, scans, and indexes all patient documents into the electronic record. Responsible for Birth Certificates. Responsible for centralized Release of Information (ROI) for Hospital and Practices. Processes all Chart Audits and HEDIS Reviews. Creates and maintains a training manual for ROI policies and procedures.

Maintains and reports ROI departmental stats to measure productivity. Ensures that all information released remains in compliance according to HIPAA, VT Law and Hospital policy.

Oversees all patient requests for amendment to Medical Records. Under the supervision of the

Manager of HIM, or designee.

Essential Functions, Duties and Responsibilities

Processes requests for health information including but not limited to those received by mail, fax, email, phone, interoffice mail, internal requests and in-person following established policies and procedures. Protect confidentiality of information by preventing unauthorized release, both verbally and/or in writing. Process ROI requests received from physicians, patients/family members, attorneys (internal & external), law enforcement agencies, insurance companies, judicial system, hospitals, State & Federal government, DCF, Disability, schools, funeral homes, and nursing facilities, in a timely manner in accordance with State and Federal regulations.

Identify any case with sensitive information prior to release and redact records as needed, and consult with appropriate management, legal team, and compliance officer regarding any potential risk management issues that need to be researched and or corrected. Log, scan & index all requests into appropriate EMR system to maintain an audit for all records released.

Prioritizes and triage all requests of records for processing.

Ensures that the consent to release medical record information is filled out properly and is signed and dated by the patient or the patient's legal representative.

Analyzes electronic medical records of discharges for complete and appropriate documentation following established criteria and regulatory guidelines. Ensures that all scanned documents in the electronic record belong to the same patient by performing 100% quality control (QC) checks.

Always demonstrates a high degree of accuracy and attention to detail. Correct other departments’ scan errors identified in the electronic chart and report to the HIM Director to be filed in the hospital incident reporting system.

Completes birth certificates and files timely with the State.

Timely processing of external annual audits for mailing and on-site reviews, i.e., Blue Cross, Medicare.

Research/merge duplicate medical record numbers.

Creates invoices and enters charges for records being released that are subject to processing fees.

Accurately prep, scan, and index all patient documents into electronic record, to include outside records/documents provided by patients requesting them to be added to their electronic record.

Keep current and maintain a manual for ongoing education on all laws and guideline changes that affect releasing of records.

Responsible for answering questions from other departments regarding compliance with releasing information, document location within the EMR, how to process certain requests for information, amendments to electronic records, and consents on file.

Work with internal quality team, hospital attorneys, clinical staff and compliance officer on subpoenas, investigations, audits and lawsuits involving records released and prepared for court.

Receives, places and transfers calls using appropriate telephone etiquette with respect for patient confidentiality. Research information necessary to complete calls received in the department.

Receives phone calls transferred by other departments to handle disgruntled customers to resolve complaints regarding issues with the ROI process.

Demonstrates an ability to communicate effectively and express ideas clearly; follows written and verbal instructions carefully. Greets and assists all visitors to Health Information

Management department.

Demonstrates a consistent level of performance, productivity; and displays a willingness to adapt to changes with job procedures or workload.

Cross-trained to cover all areas listed.

Job Requirements

High school diploma required. Medical office experience is required. Attention to detail, research, computer and electronic communication skills required. Medical terminology required. Good public relations skills necessary reflecting a positive attitude. Great teamwork skills a plus!