Under the general supervision, this position is responsible for the acquiring, analyzing, and securing digital and paper-based health and medical information vital to providing quality patient care. Ensures that a patient's health information is complete, accurate, and protected, yet readily available for healthcare providers when needed. Releases medical records in accordance with State and Federal regulations. Uses software and hardware to manage and store patient data. This position is responsible for a variety of tasks, such as, correspondence, customer service, transcription, assembly, analysis, scanning, quality assurance, and physicians incomplete. Performs other task as assigned.

Customer Service

• Provides very good customer service. Answers phone within 3 rings. Uses proper phone etiquette and customer service skills 100% of the time.
• Listens to voicemail messages regularly and follows up with return phone calls. Follows up with customers as soon as possible to provide excellent customer service.
• Assists patients, patients' family, and employees from other departments, physicians, and other visitors. Provides immediate assistance; demonstrates appropriate customer service skills 100% of the time.
• Other tasks, functions and processes necessary for departmental operation. Provides support as needed to other areas of HIM department or as needs arise.

Correspondence

• Performs release of information functions for patients, patients' family, and visitors. Provides copies (prints) of patients' medical record within State and Federal regulations. Completes requests within 3 working days.
• Performs release of information functions for all requests from outside agencies (attorney, subpoenas, physician, hospital, insurance companies, CBO, TARs, etc.). Releases patient information in accordance with State and Federal regulations concerning confidentiality. Completes requests within 5 working days and prior to due dates. Schedules appointments with copy service and records in calender.
• Orders charts located at off-site storage vendor. Ensures off-site medical records are ordered prior to 3pm each day for next day delivery prior to 4:30pm Monday through Friday. Avoids stat or rush deliveries.
• Uses Evident system to scan written requests for tracking and record keeping purposes. Scans requests, return receipts, checks received, etc. Collects fees for copying. Keeps pulled paper charts on shelfs in terminal digit order.
• Scans pulled paper charts into EMR system; quality checks scanned charts before purging.
• Responds to fax requests in accordance with State and Federal regulations. Looks up patient account number. Ensures correct patient. Completes fax cover. Ensures correct fax number. Matches fax confirmation page and scans to account in Evident.
• Picks up and drops off mail. Sorts and distributes incoming USPS mail.

Assembly, Prep & Analysis

• Print discharge list. Reconcile charts picked up to ensure received. Print facesheets. Ensure each chart has facesheet on as top page.
• Locate missing medical record not picked up (received). Follow up with email notifying HIM supervisor of missing medical record and respective department of missing medical record (not received).
• Analyzes medical records for completeness. Assigns responsible physician to missing reports/documents/signatures. Analyzes 98% accuracy within 1 day of discharge. Accurately assigns deficiency to responsible physician.
• Verify patient identification label on each page in medical record. Verifies and assigns patient identification as necessary. Ensures each page belongs to only the one patient for which the medial record exists.
• Organizes medical record into a consistent order for type of service. Inserts bar code pages as appropriate. Assembles with 98% accuracy within 1 day of discharge. Assembly includes boxing of any paper fetal monitor strips received.
• Prep medical records by removing staples, taping torn pages, tape down or copy monitor strips (be careful that edges do not fold and page is pressed against the glass), make copies as appropriate. Do not cover up any documentation and make sure copies are as good as original.

Scan & Quality Assurance

• Only after prepped and verified patient identification label on each page in medical record, (both sides of page if page is two sided); scan documents into patients account. Insert or use bar code pages as appropriate.
• Scans medical records with 98% accuracy within 1 day of discharge. This includes scanning loose filing sheets that come from units after discharge.
• Scan other HIM documents into medical record account. Scan coding summary sheets. Scan correspondence. Scan loose filing sheets or other medical record items that come late or early into department. Scan patients' medical records.
• Perform quality assurance of scanned medical records. Look to ensure entire page scanned, all pages scanned and each page is only for patient on account (no wrong patients). Makes sure ECG, monitor strips, transfer records, etc., are for patient on account only (no wrong patients).
• Corrects any errors found, and notifies HIM Supervisor(s) of error.
• After quality assurance is performed ensure chart is coded before shredding. Shreds coded charts only after quality assurance is completed.

Physician Incomplete

• Scan and assigns deficiencies to providers. Scans and assigns with 98% accuracy within 1 day of discharge.
• Works Transcription hold queue. Runs reports to manage transcription. Troubleshoots problems and notifies supervisor. Works daily and more frequently as needed.
• Clears deficiencies after provider completion. Adds or deletes deficiency notes appropriately. Runs reports to manage deficiencies. Audits deficiencies report to ensure accuracy.
• Maintains blue folders and ensures providers complete paper documents timely. Prints GI & Surgery schedules and monitors for when provider will be on site. Monitors other schedules to catch providers. Follows up with providers when they are here (face-to-face) contact. Fax providers office as necessary for record completion.
• Works Evident fax queue of transcribed dictations that failed sending to providers.
• Works Evident imports. Sends emails to communicate to appropriate parties regarding imports and exports, as applicable.
• Uploads Newborn Screening results to patients account. Ensures attaching results to correct patient account.
• Runs Evident reports, such as, Check Prior Admission Data, MPI Patient Edit, FLUE report and gives to supervisor.
• Assist providers when they are in department, in hospital or over phone.

Suspension Process

• Assigns deficiencies sent from coders and responds to their emails daily or more frequently as needed.
• Determines which providers have incomplete and/or delinquent medical records, and assigns appropriate letter for age of deficiency (creates combined list).
• Updates and maintains suspension list distributing new weekly suspension list and posting on iCare website. Ensures suspension list is accurate before publishing. (Creates suspension list.)
• Send notifications to providers using EverBridge notification system and maintains copy of message sent on shared drive. Send emails to some groups of providers in addition to the Everbridge notices. (Creates call lists.)
• Makes phone calls to providers who received letter and documents phone calls on shared drive. (Calls providers.)
• Accurately documents suspension days by physician on accumulative suspension report.
• Daily runs reports and saves on shared drive. Runs reciprocity account's report weekly.

Service Excellence: People

• Teamwork: promotes positive co-worker relationships through teamwork and cooperation. Understands and supports needs of individuals in other departments and promotes conflict resolution. Shares information, work knowledge and experience with co-workers, physicians, and others in a non-threatening manner. Offers assistance and promptly responds to requests.
• Appearance: projects a professional image. Follows the hospital dress code policy and/or department requirements. Wears hospital identification badge at all times while on duty above the waist line.
• Annual Requirements: Completes annual requirements on time (PPD, Annual Reorientation Update, any type of required training, and licensure and/or professional certifications). Demonstrates knowledge of HIPAA and hospital standards concerning the confidential nature of patient and employee information, including compliance with computer logout procedure.
• Staff Meetings: Participates actively in department staff meetings; attends 80% of meetings.

Service Excellence: Service

• Telephone Skills: Demonstrates hospital telephone etiquette by answering phones promptly (by 3 rings), courteously, and by identifying department and self.
• Customer Service: "Attitude is Everything" motto. Takes personal responsibility for providing quality services every day. Displays customer service skills by greeting all customers warmly, making eye contact, introducing self, providing assistance needed in a friendly and caring manner.
• Confidentiality: Sensitive information including, but not limited to , patients medical information, medical records, hospital documents and employee information is kept confidential.
• Chain of Command: Communicates well with supervisor, reporting problems with equipment, supplies or procedures.
• Patient Rights: Respects the rights and privacy of all patients and customers. A customer is anyone who we come in contact with, supervisors, co-workers, employees from other departments, visitors, patients, physicians, etc.

Service Excellence: Quality

• Policy ad Procedures: Understands and abides by all departmental policies and procedures as well as the Code of Ethics, HIPAA requirements and patient rights.
• General Work Habits: Readily accepts work assignments in a positive manner.
• Safety: Keeps work area neat and maintains equipment in accordance with health and safety codes. Reports safety issues and equipment failures promptly.
• Compliance: Complies with Federal, State, and Local laws that govern business practices. Complies with all Department of Health Services requirements for the State of California, and CMS standards that apply to the position.
• Integrity: Conducts business in an ethical and trustworthy manner at all times when dealing with patients, visitors, physicians, and fellow employees.
• Competency: Maintains up to date knowledge/credentials through continuing education independently.

Finance

• Attendance: Employee reports to work each regularly scheduled workday. Accurately records all work time including meal period and rest breaks. No more than one written counseling since last evaluation.
• Punctuality: Is ready for work at precise starting time and continues working until scheduled departure time. Returns on time from meal period and rest breaks.
• Fiscal Responsibility: Utilizes human and material resources of the organization responsibly.
• The WHMC HCAHPS "overall recommend the hospital" score exceeds the States average.

Growth

• Opportunities: Communicates opportunities to improve care or service.
• Goals: Established yearly goals that will enhance personal job performance.
• New Initiatives: Tries new approaches to problem solving, reaching goals, and/or new programs. Strives to be flexible and adapts to change.

• Minimum Education: High School diploa or equivalent, enrollment in registered Health Information Technology program preferred.
• Minimum Experience: Minimum of two years HIM (medical records) experience preferred.
• Required Certification/Registration: None; Registered Health Information Technologist (RHIT) preferred.
• Professional Requirements: Medical terminology; ability to pass departmental skills testing exam.