US:NV:Carson City Health Information Management
Full Time Day Shift
Summary
The HIM Tech 2 assists members of the medical staff in maintaining medical record completion and compliance in accordance with hospital accreditation standards, Federal, State and /or other regulatory agencies. Works collaboratively with other members of the HIMS Department to complete all essential responsibilities in a timely fashion to meet the quality, utilization, and financial needs of the organization.
Qualifications
Required
o High school graduate or equivalent.
o Minimum 3 years of previous healthcare clerical experience, analyzing medical records, training others on medical record processes. Or 2-year experience as an HIM tech 1.
o One-Year computer or EMR experience
Preferred
o Medical Terminology course.
o AHIMA education or certification
o Knowledge of HIPAA compliance
o Knowledge of Electronic Medical Record systems
Essential Functions
- Complete deficiency analysis for all patient encounters as assigned within the electronic medical record. Index and validate all patient encounters to ensure documents are appropriately catalogued within the medical record.
- Adhere to hospital accreditation standards, Federal, State and/or other regulatory agency standards for appropriate analysis of documentation and signature requirements.
- Track and distribute medical record completion compliance information to the Department Managers of the Medical Staff, Medical Staff Services, Quality Management and other appropriate personnel.
- Monitor the completion of deficiencies within the electronic medical record. Escalate deficiency issues in accordance with medical staff, and departmental policy.
- Process any incoming documentation and dictation ensuring accuracy, completeness and timeliness according to policy and laws.
- Provide assistance and training for various HIM systems. Including initial training and follow-up training for providers in transcription, dictation, and EMR usage.
- Takes department phone messages as needed, and routes calls appropriately. Follow-through for any phone calls related to HIM operation's needs.
- Act as an active member of the quality committee, forms committee, and Transcription committees as requested by leadership. Provide feedback, and analysis of impacts to the HIM department, and trends from the HIM perspective.
- Ability to perform all essential functions of the HIM tech 1 or coder/biller functions, as needed. Including ROI, prepping charts, scanning, documentation upload, loose work, charge capture, and quality review.
- Collaborates with physician practices, medical staff, quality, and revenue cycle departments to ensure timely, accurate patient charts, and timely billing.
- Reviews requests for identity validation, duplicate MRN processing, and ensuring a clean eMPI for CTH.
- Processing, communication and completion of the State of Nevada Vital Records Birth process, as needed.
- Performs other related duties and projects as assigned.