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SoutheastHEALTH Health Information Technician in Dexter, Missouri

Health Information Technician

Administrative - Clerical Dexter, MO Health Information Management Full-Time



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

Document Imaging

  • Retrieves paper medical records/loose sheets from identified hospital units and clinics per the rounding schedule delineated in the Document Retrieval & Scanning Schedule policy

  • Processes all loose sheets according to established prepping and scanning procedures to ensure a complete medical record for every patient encounter

  • Cleans scanner on a daily/weekly basis, as needed, according to instructions

  • Places complete batches in appropriate area for indexing and final quality check

  • Performs a final quality check after the scanning procedure to assure capture of and correct placement of every document in the correct work type folders in the correct patient records in the EHR

Release of Information

  • Verifies authorization of and coordinates the release of medical information for all requests, including patient, physician, other healthcare provider, third-party payers, CMS, and attorneys, in accordance with Hospital and Departmental policies and Federal and State laws

  • Copies and faxes records as needed for continuity of care

  • Upholds security and confidentiality regulations for record access and review Alerts Director of unusual requests

  • Instructs hospital personnel, patients, and other healthcare providers of the policies and procedures for release of medical information, including review and return of record(s)

  • Reports medical data to healthcare professionals in accordance with Hospital and Departmental policies

  • Processes birth certificates and advance directives or other legal documents received according to Department procedure

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(s), as applicable

  • Correctly identifies when documentation has not been created and assigns to responsible physician(s)

  • Maintains analysis turnaround within required time frame

  • Generates physician notification letters according to specified policy

  • Whenever possible, answers any questions clinicians have about their deficiencies and how to access assignments/complete deficiencies or directs to appropriate person for clarification

  • Monitors the HIM Refusal Inbox in Message Center daily and reassigns deficiencies when appropriate

  • Provides daily reports to hospital personnel/departments as needed on incomplete records and physician suspensions according to procedure

  • Processes physician suspensions per hospital policy

  • 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

    Provider-Created Documentation QA

  • Randomly audits documentation created utilizing front-end voice recognition, comparing documentation to voice file, notifying providers of critical medical errors and the need to amend records per hospital policy

  • Prepares a monthly dashboard for the HIM Director of audit results to share with Regulatory Compliance

  • Notifies providers and hospital staff of documents in "saved not signed" or incomplete status

  • Processes misdirected faxes

  • Monitors the Rejected Documents daily that are routed to HIM via fax

  • Prints and faxes corrections to the appropriate location daily, routinely monitoring EDM for correct documentation placement

  • Analyzes the quality and provides oversight of day-to-day front-end voice dictation issues identified and seeks assistance of director as needed

Retrospective Record Review

  • Randomly audits discharged encounters for Joint Commission and CMS required elements contained in the medical records

  • Prepares a monthly dashboard for the HIM Director of audit results to share with Regulatory Compliance

  • Notifies Provider-Created Documentation QA staff of critical documentation errors discovered during random audits


  • Reads email daily and responds as necessary

  • Assures confidential handling of all protected health information

  • Attends and participates in regularly scheduled department meetings and mandatory training; assumes responsibility for all information communicated at meetings missed

  • Monitors daily work queue and notifies HIM Operations Supervisor and/or HIM Director if assistance is required to maintain excellent customer service

  • Meets or exceeds established department productivity expectations

  • Abides by all Hospital and Department policies and procedures

  • Performs any other duties as assigned


  • High school diploma or equivalent required

  • Credentialed as a Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) preferred

  • Experience working in an HIM Department preferred

  • Experience with various computer applications (Microsoft office products, Outlook, etc.) preferred

  • Experience utilizing a phone/fax machine, printer, copier, and other miscellaneous office equipment preferred