USA

HIM/MEDICAL RECORDS CLERK

locationHighlands Ranch - Colorado (CO), 80130

atHighlands Behavioral Health System

Estimated salary $40,000 a year

Job Description:

Responsibilities

Highlands Behavioral Health System is an 86 bed, acute care psychiatric hospital located in Littleton, CO. Highlands features individual units for adolescents, adults, and seniors, and offers inpatient acute care, partial hospitalization, and intensive outpatient programs.

Do you thrive in a challenging and rewarding work environment? Apply today for this PRN Weekend position. Pay range is $12.00-$16.00 per hour DOE.

The HIM Technician, under general supervision of HIM Manager performs clerical tasks related to preparation of medical record files, assembly & analysis of the inpatient medical record, identification of medical record deficiencies as well as data entry of the medical record deficiency into the computer software. HIM Technician assists physicians and staff with chart location and medical record completion as defined by Joint Commission, state, federal medical record requirements, corporate, and hospital policies.

Qualifications

JOB RESPONSIBLITIES:
  • Using the ADT Report retrieves discharged medical record from the inpatient units the day after discharge with the exception of weekends and holidays.
  • Following the established order of assembly and filing protocol as referenced by policy and procedure Assembly of Inpatient Medical Records assembles the discharged inpatient medical record the day after discharge. Accurate assembly of an inpatient medical record consists of: accurate creation of medical record files, correct assembly order, creation of additional volumes as needed, completion of routing card, as well as maintenance of the departmental production standard of discharged medical records being assembled within 24 hours of discharge with the exception of weekends and holidays. The productivity standard for assembly of an individual medical record is 15 minutes per medical record with a 90% accuracy rate.
  • Accurate analysis is accomplished by observation of policy and procedure Analysis of Inpatient Medical Records. Assembled medical records are analyzed for deficiencies as defined by Joint Commission, state and federal medical record requirements, corporate, and hospital policies. Deficiencies are tagged for completion and entered into the hospital software. A deficiency sheet is printed by the HIM Technician and placed in the medical record on top of the patient face sheet. The departmental production standard is that all discharged medical records be analyzed within 24 hours of discharge with the exception of weekends and holidays. The productivity standard for analysis of an individual medical record is 15 minutes per medical record with a quality standard of 95%.
  • Completes the photocopying, faxing, and mailing of designated medical record reports to community providers at discharge in accordance with HIM Release of Information Protocol for Aftercare Release of Information . Departmental standard is to fax/mail medical record reports within 24 hours of discharge with the exception of weekends and holidays. Productivity standard for mailing/faxing an individual medical record request is 10 minutes.
  • Pulls and prepares medical records for hospital and medical staff requests. Delivers medical records to physicians and other staff as requested. Responsible for accurately tracking the location of a medical record and subsequent return of the medical record by the end of the HIM Technician’s shift.
  • When pulling records for chart completion, the HIM Technician, pulls charts using the most current Medical
Record Deficiency by Provider printout. The oldest aged charts are prioritized for completion based on the true age of the deficiency.
  • When a medical staff member completes a medical record, the HIM Technician is responsible for the accurate removal of the deficiency with a 98% accuracy standard. HIM Technician is responsible for verifying the removal of the deficiency against the printing of the medical staff member’s deficiency list.
  • Works directly with physicians and physicians’ offices to resolve deficiencies.
  • Using the computer entry software, performs weekly reanalysis of the discharged medical record with a productivity standard of 5 minutes per individual medical record. Reanalysis incorporates the following responsibilities: deleting or adding deficiencies, deficiency slip accuracy, verification that all reports and documentation belong to the patient, and assurance of accurate location of medical record including maintenance of terminal digit order.
  • Monitors physician completion of medical records to assure completion of medical record within 30 days of discharge. Advises HIM Manager weekly of deficiencies that exceed 30 days aged.
  • On a daily basis processes physician dictation. HIM Technician crosschecks dictation against the Transcription Log. HIM Technician is responsible for filing unsigned dictation in individual medical staff signature folders in terminal digit order.
  • Assures and verifies that all dictation has been signed before placing the original in the medical record.
  • Schedules and completes monthly audit of chart locator file cards. Quarterly, completes an audit of incomplete medical records.
  • Responds to authorized requests for release of information according to state and federal regulations as well as hospital policies. HIM Technician ensures that information is only released upon receipt of a HIPAA compliant release of information and that the minimum necessary standard is followed with respect to release of information. Requests are processed within the required timeframe and meet departmental quality standards.
  • As a thorough working knowledge of HIPAA Privacy policies and procedures as well as 27-10 and can assist patients and staff relative to HIM Department responsibilities regarding authorizations, patient access, request for amendments, accounting of disclosures, and minimum necessary standards.
  • Identifies inactive medical records for removal from the active files according to the criteria established by HIM Manager. Coordinates archiving of the inactive medical record twice a year.
  • On an ongoing basis assures that loose filing is current and filed accurately in the proper medical record in the established chart order with an accuracy rate of 95%.
  • For RHIT Technicians, coding with 95% accuracy and meeting the standard of no less than 3-4 charts per hour.
  • Provides back up coverage ,support for HIM staff, and other duties as requested.BEHAVIORAL EXPECTATIONS:
  • 1. Fosters collaboration and teamwork; asks for help as needed and offers assistance to others when available. 3. Promotes a welcoming environment for all co-workers, patients, families and visitors by treating them with courtesy, dignity, and respect.
  • EDUCATION/EXPERIENCE:Education – Ability to read, write, speak, and comprehend the English language with a high school diploma or the equivalent.
  • Experience – Minimum of one (1) year health related work experience, preferably in a Health Information Management Department. RHIA, RHIT, or eligibility for credentialing examination may substitute for experience .
  • Similar Jobs in Colorado