Monday - Friday: 8:30am-5:00pm
Job Summary: Protects and maintains the security and confidentiality of patient data and medical information. Ensures integrity of all clinical documentation images and Master Patient Index by performing the functions of prepping, scanning, indexing and quality audits/control of all medical record documents in a timely and accurate manner. Facilitates electronic health record documentation completion by identifying all deficiencies and assisting physicians in the electronic completion of them. Handles all aspects of preparation and distribution of information available in the patients’ legal health record as requested by appropriate individuals and hospital departments. Preserves the integrity of the Legal Health Record and adheres to all policies and procedures.
Position Responsibilities:
- Responsible for document capture of paper records (including prepping, scanning, indexing, quality review, etc.) into document management system (OnBase), and manages electronic images in OnBase and Epic (Electronic health record).
- Assesses all scanned images against accuracy and quality requirements, monitors manual index queues of unassigned images and maintains scanning equipment according to procedure for optimal performance.
- Responsible for daily monitoring and completion of Epic In-basket work queues for MyChart and Release of Information requests and PAT Work queues in OnBase for scheduled surgeries.
- Ensures accuracy of demographic information, including identification of patient merges/duplicates, baby name changes in Epic ensuring accuracy with state registry application, and other system updates.
- Performs analysis of documentation and accurately assigns physician/provider deficiencies to ensure timely completion and adherence to regulating agency requirements for completion of legal health records (DOH, CMS, Joint Commission, Medical Staff Rules and Regulations, etc.).
- Provides assistance, education and guidance to physicians/providers for completion of any deficiencies.
- Responsible for validating accuracy of physician/provider deficiencies on incomplete medical records, identifying and notifying physicians who are eligible for suspension by electronic delivery using the EPIC EHR system.
- Monitors timely completion of medical records and sends suspension letter notification to physicians who have not completed their delinquent charts in the appropriate timeframe, according to Medical Staff rules, regulations and bylaws.
- Validates multiple system interfaces to ensure receipt of accurate clinical information into the electronic legal health record; reports and escalates discrepancies.
- Assists with monitoring and tracking unbilled accounts: Helps troubleshoot accounts on the Discharged Not Final Billed report to aid department in meeting Accounts Receivable goals, utilizes inter-departmental shared files, and communication workflows within Epic in order to resolve issues, performs corrections of registration data of patients’ post discharge and escalates as appropriate.
- Reconciles paper medical records with hospital census to ensure receipt of all patient records.
- Maintains paper record storage areas for accessibility until destruction of original documents ensuring all records are securely maintained. Performs final quality control review of paper documents prior to destruction.
- Ensures flow of clinical documentation to appropriate work queues for internal and external audits.
- Performs and participates in quality audits and reviews. Discloses patient information to appropriate parties and ensures that information that is released from HIM is in accordance with applicable regulations and guidelines.
Position Qualifications Required:
Required Experience:
- 2 years of medical office experience required or equivalent in education (minimum of AAS in HIM).
- Strong Knowledge of medical record format.
- Ability to perform computer functions in a Microsoft Windows environment.
- Ability to be detail-oriented and perform tasks at a high level of accuracy.
- Ability to make sound decisions and demonstrate teamwork skills.
- Demonstrates strong verbal and written communication skills; customer service focused.
- Ability to operate scanning hardware preferred.
- Previous experience in a hospital HIM department preferred.
- Previous experience with an electronic legal health record system preferred.
- Knowledge of medical terminology preferred.
Required Education:
High School diploma or equivalent.
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