Position Objective:

The primary responsibility of the Health Information Technician II is demonstrating all duties assigned as a HIM Technician I along with processing all requests for release of medical records, analyzing medical records after discharge to ensure compliance with hospital medical staff bylaws and Joint Commission standards for completion of medical records, generating provider deficiency letters, monitoring transcription and scanning error queues,  and other general administrative duties and special projects or reports assigned by HIM management team to support data integrity of the medical record.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

1. Acquires clinical and administrative documentation for the legal medical record through daily rounds of patient care areas.  Completes discharge check in verification and missing chart list on a daily basis.  Prepares, scans, and indexes all document types to the correct patient, encounter, and document type.  Performs real-time quality review of all documents and post-processing QA of clinical documentation.  Monitors and processes any documents in the scanning error queue.
2. Provides customer service including front desk, phone coverage, and release of information support.   Distributes departmental mail and utilizes transcription tracking system to research and respond to requests regarding dictated reports.  Distributes provider copies of transcribed reports including endoscopy reports.  Applies appropriate flags to records as requested in accordance with department policy.  Monitor failed fax reports and resend appropriately.
3. Enters all requests for release of information within the electronic health record system.  Reviews each request for information to determine urgency and assures that urgent requests are completed first using established priority. Evaluate the adequacy of each completed authorization form to ensure it meets HIPAA requirements and is completed correctly.
4. Analyzes medical records for discharged encounters according to established procedures and guidelines while maintaining a productivity rate of 9 charts per hour with 98% accuracy rate for deficiency assignment.  Processes all assigned work queues including done/declined and verification.
5. Accurately evaluates delinquent deficiencies that are eligible for the provider deficiency letter process, generate appropriate deficiency letters, and send to providers. Respond to emails and phone calls from providers with questions about deficiency letters and provide guidance to providers on what needs to be completed to satisfy hospital and regulatory requirements. Provides support and guidance to providers with navigating through provider in basket folders and performing basic in basket functionality.  Updates provider status including out of office and termination when notified.
6. Troubleshoot and resolve transcription errors in the electronic health record error queue and transcription system promptly. Communicate effectively with other departments, physician practices, and transcription vendor to resolve transcription errors.
7. Navigate through documents, visit information, and use reports in the electronic medical record to find needed information to fully understand the content of a patient’s record in order to research and solve documentation issues or missing information needed for coding, release of information, etc.
8. Seeks assistance and support when appropriate.  Monitors quality of own work and reporting of productivity on a daily basis.
9. Ensures that any task started during scheduled shift is completed by end of shift or appropriate hand off is made to next shift.
10. Accurately updates internal dashboards in a timely manner as requested.

Educational/Experience Requirements:

• High school diploma or GED equivalent.
• Minimum of one year’s health information management experience in an electronic health record environment or RHIT/RHIA eligible is required.  Associate or Bachelor’s degree preferred.
• Medical terminology and knowledge of Microsoft Excel (import, export, graphs, and pivot tables), Word and Outlook is preferred.
• Familiarity with EPIC, Hyland OnBase, as well as previous data entry experience is preferred.
• Previous experience in record review, analysis, deficiency assignment, record completion, customer communication, and regulatory requirements related to record completion and privacy/security is preferred.

RequiredLicense/Certifications:

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands – Medium

Medium work: Exerting up to 50 pounds of force occasionally, and/or up to 20 pounds of force frequently, and/or up to 20 pounds of force constantly to move objects.  Alternating periods of extended walking and sitting with computer/keyboard work.

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position.  This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.