Job Opening for HIM Technician II | Medical Records
Responsible for training and assembling records, releasing copies of medical records in accordance with hospital policy and Federal and State laws, and file and retrieve medical records.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Clinic - In addition to Tech 1 responsibilities - responsible for training of new staff for clinic medical record duties; order new files, and supplies as needed for charts; enter passwords in Winscribe for any new physician for dictation purposes and disconnecting physicians in Winscribe system when having trouble with dictation; collect all superbills sorting in chronological order to match with clinic dictation for billing department; run missing dictation report and research if dictation is not done; responsible for pulling charts for Healthport for all release of information for clinic and hospital, checking charts so no duplications are sent; assignment work link, communication between the business office and work with business office staff with any request, pulling dictation, etc; contact person for the funeral home, complete death certificates online, verify with provider, and check upgrades on the system; Annual Clinic Peer Review process, check clinic records for accuracy and completion in addition to assembling records, releasing copies of medical records in accordance with hospital policy, Federal and State laws; on HIPAA committee; entire set up for Net labels for clinic and hospital charts.
Hospital - In addition to Tech 1 responsibilities - responsible for training of new staff for hospital medical record duties; order new files, and supplies as needed for charts; assignment work link, communication between the business office and work with business office staff with any request; created an orientation book for new providers and maintains with any updates; responsible for contacting provider if dictation is needed while patient is hospitalized; responds to any and all requests regarding the hospital record and contacts IT department if this involves the EHR; reviews each inpatient charts for required Care Plans prior to discharge from the hospital, contacts nursing to initiate if not complete; on HIPAA committee; completes closed chart review, reviews and investigates charges and contacts appropriate departments for additions and/or corrections; knows the NESIIS (Nebraska State Immunization Information System) for immunizations and trains staff; and complete death certificates online and verify with provider;
- To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and /or ability required.
- Ensure confidentiality of patient information.
- Assemble medical records into standard chart format and maintain chart order.
- Uphold HIPAA and confidentiality regulations of record access and review. Alert HIM Manager of unusual requests for records.
- Send out medical record information upon request while meeting HIM and HIPAA guidelines.
- Send out medical record information upon request for all state licensures and medical registries according to state and federal regulations.
- Assemble acute, observation and surgery charts.
- Critique charts as assigned by HIM Manager.
- Maintain a log of all records requested and sent out.
- Answer and route incoming calls.
- Assist in filing all medical records in an orderly fashion.
- Use department computers in an appropriate, efficient manner.
- Assist all departments throughout Saunders Medical Center to locate needed reports or records.
- Participate in quarterly quality management studies.
- Maintain a log and destroy records according to policy and state regulations.
- Participate in all safety, security and infection control programs that are mandatory as well as those required and provided by the department.
- Uphold confidentiality and HIPAA compliance at all times and report violations to the Privacy Officer.
- Understand and comply with the requirements of the Saunders Medical Center’s Compliance Program, including, but not limited to the Code of Conduct, the Compliance Policy, all Saunders Medical Center-wide policies for compliance, and compliance plans affecting specific duties and responsibilities.
- Participate in all education and training programs regarding compliance as required by Saunders Medical Center policy and as requested by the Manager.
- Demonstrate personal traits of a high-level commitment, motivation and energy; team orientation; professionalism; trust; personal honesty and integrity; and a demonstration of placing others in a place of high value and treating them with dignity and respect.
- Other duties as assigned by the Manager.
Acts as a liaison between staff and management. Accepts training responsibilities for departmental staff.
The above statements reflect the general details considered necessary to describe the essential functions of the job as identified, and shall not be considered as a detailed description of all work requirements that may be inherent in the position.
EDUCATION and/or EXPERIENCE
- High school diploma or equivalent.
- Experience in medical field as it relates to medical records.
- Proficient in computer and typing skills.
CERTIFICATES, LICENSES, REGISTRATIONS
Must be able to read, write and follow written and oral instructions and possess positive skills in communication. Ability to deal tactfully with personnel, patients, visitors, and the general public.
Ability to calculate at the level necessary to perform essential duties of the position.
Ability to make independent decisions when circumstances warrant such action. Ability to interpret a variety of instructions furnished in oral, written, diagram or schedule form.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing this job the employee must sit frequently and spend long periods of time examining documents. The employee must stand, reach with arms and hands and occasionally lift, push or pull 50 pounds. The employee must occasionally walk and climb or balance.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position. Attendance is essential and required for a successful working environment.
Become a Health Information Management Tech II near Lincoln, Omaha, and Fremont. We are located just 30 minutes away in Wahoo!