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SoutheastHEALTH Health Information Technician in Cape Girardeau, Missouri

Health Information Technician

Administrative - Clerical
Cape Girardeau, Missouri

CVC Of SoutheastHEALTH Part-Time

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Description

Day ShiftThe HIM Technician is responsible for performing specialized tasks that affect external and internal customers of the HIM DepartmentBegin

Document Imaging

  • 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

  • Other duties as assigned

SECONDARY RESPONSIBILITIES:

Deficiency Analysis

  • 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.

  • Attends and participates in department meetings and is responsible for all information communicated at the meetings.

  • Meets or exceeds productivity expectations established by HIM Director.

  • Performs other duties as assigned.

Release of Information

  • 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

  • Attends and participates in department meetings and is responsible for all information communicated at the meetings

  • Meets or exceeds productivity expectations established by HIM Director

  • Performs other duties as assigned

Become

  • High School Diploma or Equivalent

  • Must be able to read, write and speak English

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