Health Information Management (HIM) Records Technician, Senior

Position Summary

The Health Information Technician Senior is responsible for advanced level problem solving, organizing, training, and communicating within the department and organization; demonstrates the ability to identify serious quality issues in the EMR and knows the appropriate actions to either report or correct the finding. This position is responsible for evaluating the day-to-day activities and task assignments in conjunction with leadership directing other staff members in the area and providing training/retraining for all staff and will have an understanding of privacy and security guidelines related to patient information and maintain HIPAA as well as keep all patient information confidential.

The HIM Records Technician Senior is responsible for document scanning/imaging and paper chart training, auditing, mentoring, development of training materials, workflows and programs, assisting in change management and back-up support for all tasks during vacations, illnesses, and vacancies. The HIM Records Technician Senior will monitor day to day assignments to ensure work is completed in a timely manner. The incumbent is responsible for daily huddles, monitoring and handling all scanning/indexing corrections, reporting potential issues to the Identity team, monitoring inventory, providing reports, and working reports/queues along with system/workflow testing.

The HIM Records Technician Senior will have direct contact with CCOC staff including department heads, secretaries, physicians, nurses, unit clerks and other internal support staff as well as external customers including patients/representatives, attorneys, insurance companies, joint venture sites, community connect partners and other healthcare facilities (physicians/nurses), etc.

Essential Job Functions/Accountabilities

Daily quality auditing of document sorting, look ups, prepping, scanning and indexing including recording of data and providing reports to management; along with Quality monitoring of and communication with contracted vendors, such as release of information.

Works under the direction of the HIM Manager, and is additionally responsible for processing the release of medical records and health information management as it pertains to sensitive legal and government audits. This position backs up the department manager in a variety of clerical support functions, as needed. Daily monitoring and tracking of inventory and assignment of work tasks, adjusting assignments based on priorities; Daily review and processing of workflow management reports and assist leadership in review of new documents “to scan”, develop workflows and provide on-going training.

Audits and processes all analysis work queues/ Index queues to ensure timely completion of all referrals, priority scanning and document corrections. Index and communicate in work-queues within the EMR and acts as lead support for patient portal inquiries/troubleshooting and escalates to HIM Supervisor as needed.

Review questionable documents, refer to leadership as needed. Assists clinician/ providers with chart correction functions in Cerner, Athena and/or other electronic system usage relative to medical record deficiency completion. Coordinates with clinicians, coding/billing and clinic support teams to provide completeness and accuracy. This may include documentation creation in the EHR, such as transcription, and may require travel to provider location for in-person interaction, training or assistance.

Assists manager with training all allied health professionals credentialed with the CCOC on: Cerner, EWS, Nuance and dictation, completion of paper records, etc.; assists various departments with questions and documentation needs; assure provider completion on required entries; assure completion of legal record; audits inpatient and outpatient surgical accounts for accurate assignment of physician deficiencies, prepping and scanning based on the criteria established by the CCOC.

Completes assigned potential duplicates reports according to department and EMR procedure; thoroughly reviews/ researches potential duplicates before merging medical records in EMR(s). Ensures the chosen action performed is based on evidence (three consistent identifiers). Investigates demographic changes for validity and accuracy. Ensures any changes made to demographics have supportive documentation provided. Questions any changes without provided documentation. Informs the registration staff of the information necessary to proceed with a change or merge.

Responds to telephone or email requests from registration/scheduling and PACS areas to update patient demographics or merge medical records in EMR(s). Ensures all requests are completed in a timely manner. Communicates effectively using written/verbal skills. Maintains a professional and friendly demeanor. Assist in focused audits, training and re-training. Provide objective reports on individual training progress. Develop and assist in specific clinical scanning projects; as needed, able to perform all Health Information Specialist Technician job duties.

Monitor daily reports, audits and inventory, ensuring all tasks are completed in a timely and accurate manner; Provide accurate and timely maintenance and repair of medical record charts that have been requested; Deconstruct and prepare paper charts for back scanning along with scanning and indexing following established protocols.

Lead Work Duties: Function as Super Users for all systems used by HIM Document Imaging; plans, assigns, and guides the work of HIM team function when technical support of document imaging and medical files functions are needed. Conduct special searches or audits as per regulatory guidelines and governing bodies as requested by leadership.

Coordinates weekly medical staff notice for impending suspension or incomplete record notices; reports to manager with delinquency rates, reports and charts as necessary; may participate in interview and selection of new candidates; assists supervisor with bill select error reports; coordinates training and performance improvement for probationary staff; monitors and corrects the prepping, scanning and analysis errors and assists with additional training if needed.

Assists in the development Develops and/or revises policies and procedures affecting the technical support of the document imaging and medical files functions; may assist with leading meetings records, daily huddles and/or note taking for meetings; may additionally attend steering committee meetings and provide input as needed.

Trouble shoots and contacts appropriate areas for resolution during downtime and system inoperability.

Abides by the AHIMA Code of Ethics.

All other duties not specifically assigned.

Position Requirements

Education: College degree or progress towards degree, preferred.

Experience: Three (3) to Five (5) years of demonstrated experience in field or professional experience to CCOC preferred; OR two plus (2 ) years within CCOC Health Information Management Department as a HIT I, preferred. Proficient knowledge of EHR is required.

Technical Skills: Employee should demonstrate a cooperative behavior with colleagues and supervisors; the employee shall work well under pressure, meet multiple and sometimes competing deadlines; ability to organize and prioritize work; accuracy and speed is required and an ability to handle repetitive job and stay focused; Basic knowledge of medical terminology a must; Experience using clinical computer systems (i.e Microsoft office Suite, Printers, Copy Machine, Multi-Line Phones, etc) required.

Certifications/Licenses/Registrations: N/A