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SalaryDescription
Home Health | Cape Girardeau, MO | Full Time
Job Summary
The HIM Technician is responsible for performing specialized tasks that affect external and internal customers of the HIM Department including: Deficiency Analysis: Ensures the patient record contains documentation elements required by Federal and State law as well as accrediting bodies and Medical Staff Bylaws, Rules and Regulations. Facilitates timely completion of the medical record by reviewing each discharged patient's record for incomplete or missing items; identifies the responsible practitioner for each of these items, and links the deficiencies to the appropriate physician for completion. The HIM Technician will be responsible for verifying chart completion, identifying those physicians who will have their admitting and/or surgical privileges suspended and notifying appropriate hospital personnel/department of physician suspensions. Release of Information: Ensures that information from a patient's record is released only when authorized by the patient and/or the patient's legal representative and in accordance with Federal and State laws as well as Hospital policy. The HIM Technician will respond to requests for copies of or access to patient information from patients, attorneys, insurance companies, other healthcare providers, subpoenas and others. Coordinates record reviews by internal and external auditors, monitors record returns, and guides other requesters relative to access to and release of information. Document Imaging: Ensures that all patient records and loose documents are appropriately prepared and flawlessly scanned into the Electronic Patient Folder and accurately indexed by document type to the appropriate patient folder facilitate timely retrieval.
Essential Functions
- Retrieves all non-electronic records of discharged patients from all units on a daily basis
- Check daily discharge log to ensure receipt of all records and follows up on records not received
- Ensures that all patient records are received with within one day of discharge, reporting to the Director when unable to obtain a patient record
- Checks each patient record for poor originals and stamps with “poor original” stamp according to documented procedure
- Removes all photographs and other difficult to scan documents from the patient record in order to be scanned and indexed separately utilizing the flatbed and/or color scanner
- Prepares all document by removing staples, paper clips, sticky notes and rubber bands
- Sorts all documents in date order
- Copies all damaged documents so that they can go through the scanning process without jamming, distorted imaging, or other difficulty.
- Securely attaches all rhythm strips and other small documents to 8 ½ X 11 paper for scanning
- Assembles all documents according SEH's universal chart order.
- Prepares loose sheets for scanning according to procedures
- Creates loose sheet batch of appropriate size according to procedure.
- Places all batches in appropriate area for scanning
- Retrieves records from scanning shelf and performs scanning process according to procedure
- Maintains appropriate set up for scanner to ensure optimal image results
- Verifies that each batch has been prepped appropriately, removing documents that cannot be scanned and removing staples, paperclips, etc.
- Cleans scanner on a daily/weekly basis according to instructions
- Places complete batches in appropriate area for indexing
- Reviews 100% of images scanned
- Identifies at least 98% of documents that are of poor quality
- Ensures that all scanned documents are positioned correctly
- Indexes documents to correct encounter and document type
- Accurately performs indexing process
- Each document is indexed to the correct patient/encounter
- Each document is assigned the correct document name
- Verifies that bar-coded documents are correctly indexed
- Identifies when it is appropriate to split and merge documents
- Splits and merges documents correctly
- Correctly inserts pages/documents when and where appropriate
- Correctly appends pages/documents when and where appropriate
- Writes each indexed batch to the appropriate queue according to workflow procedure
- Reviews assigned work queue(s) daily and ensures timely processing of all assignments in the queue(s)
- Corrects transcribed reports as needed
- Attends and participates in department meetings and is responsible for all information communicated at the meetings. Attends all mandatory hospital and department in in-services
- Meets or exceeds productivity expectations established by HIM Director
- Selects appropriate assignments for analysis from work queue
- Reviews each record for missing documents, missing signatures or missing text according to procedure
- Accurately assigns deficiencies to physician(s) according to procedure
- Links signature deficiencies for COLD fed documents to correct physician, if applicable
- Correctly identifies when dictation has not been done and assigns to correct physician
- Maintains analysis turnaround within required time frame
- Generates physician notification letters according to specified policy.
- Whenever possible, answers any questions the physicians have about their deficiencies and how to access assignments/complete deficiencies or directs to appropriate person for clarification.
- Monitors reanalysis queue (physician decline queue) daily and reassigns deficiencies when appropriate.
- Provides daily reports to the hospital personnel/departments as needed on incomplete records and physician suspensions according to procedure.
- Prepares physician suspension list after: Sending physician first notices / Sending physician suspension notices 48 hours prior to actual suspension
- Performs reanalysis process within quality standard.
- Maintains integrity of incomplete charts within quality standard.
- Proactively contacts physicians and creatively encourages physician compliance with timely chart completion policies.
- Coordinates the release of medical information to all requests, including patient, physicians, other healthcare provider, insurance companies, and attorneys, in accordance with hospital policy and state and federal laws
- Copies and faxes records as needed for continuation of care
- Verifies authorization in accordance with hospital policy and state and federal laws
- Upholds security and confidentiality regulations for record access and review Alerts Director of unusual requests
- Instructs hospital personnel, patients, and other health care providers of the policies and procedures for release of medical information, including review and return of record(s)
- Reports medical data to health care professionals in accordance with hospital and departmental policies
- Takes appropriate information for record requests and uses the computer to verify demographic information
- Prepares and mails legible copies to requesters, and submits charges to the requester for billing of photocopy charges when indicated
- Ensures that only those records required to fulfill the request are supplied to the requestor 100% of the time. (Minimum Necessary Rule)
- Ensures that only those records requested by the requestor are sent to the requestor 100% of the time. (Disclosure Rule)
- Immediately notifies Director if records have been disclosed inappropriately. (Breach Rule)
- Logs all disclosures, regardless of whether they were in-person, fax, or mailed by end of day 100% of the time Any other duties as needed to drive to the Vision, fulfill the Mission, and abide by the Values of the organization
Qualifications
- High School Diploma or Equivalent required
- Minimum of 1 year In Healthcare field preferred
