Health Information Management (HIM) Specialist

Under general supervision, the HIM Specialist will perform work within one or more of the functional areas within HIM. Responsible to maintain patient health information files, performs chart location and tracking, scanning and quality of documentation in the Electronic Health Record, provides release of health information to various parties, and ensures accuracy and completeness of the medical record.

Essential Job Functions

• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
• Scans patient documentation according to established electronic health system order Responsible for researching missing documents and ensuring all patient documentation is consistent, belongs to the patient and present at the time of discharge.
• Retrieves patient charts at discharge and responsible to verify against ADT report that all records have been received. Initiates follow-up calls to nursing unit to obtain any records not received. Locates missing charts through utilization of chart tracking software, CIS software to determine nursing unit where patient was treated and physical searches of nursing units.
• Prepares and organizes documents for the imaging process, determines correct settings to ensure quality of each document, indexes scanned records and analyzes them for clarity and accuracy.
• Answers the telephone and is responsible to provide requested information through independent resolution utilizing research skills, document production, and data analysis techniques. Accurately fills requests for transcribed documents or prior patient medical records using available systems such as CIS, ChartLocator, SMS and Misys. Must be able to perform research to respond appropriately to caller by providing requested information for patient care.
• Determines and appropriately locates medical records in the electronic health system (CIS). Locate historical paper medical record location utilizing software such as Mysis, ChartFact/Locator, SMS and microfilm.
• Performs final verification of medical record completion prior to completing chart from task queues. Verification includes reviewing all appropriate documents to ensure they have been signed and/or properly documented by a physician or qualified healthcare provider, the documents are in the proper location of the EHR, and all patient information is consistent and all documents specified by accrediting and regulatory agencies are included in the medical record.
• Analyzes medical records for chart completion deficiencies as mandated by JCAHO, Medicare, Medicaid and/or other accrediting or regulatory bodies. Determine appropriate physician to provide missing documentation, (i.e., attending physician, surgeon, etc.). Perform re-analysis when physician has supplied missing items to ensure completeness. Assists physicians with chart completion by providing appropriate medical record, responding to questions regarding regulations related to the provision of documentation and updating the deficiency system.
• Works with HIM Leadership compile and analyze chart deficiencies weekly and notify physician(s) of aging of deficiencies. Responsible to determine appropriate notification based upon type of deficiency and aging.
• Assesses quality of scanned documents on a daily basis. Measures results against established quality standards and provides feedback to HIM Lead and with HIM staff as needed to improve quality and/or provide education and training.
• Responds to requests for patient healthcare information. Responsible to verify a compliant authorization has been provided and copies appropriate documentation based on upon the compliant authorization.
• Maintains or exceeds 95% accuracy based on audit findings. Maintains or exceeds 90% department productivity standards for assigned tasks.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental and outside agency safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization.