HIM Tech II

About the opportunity:

Accurately processes medical records, including document capture; identifies documentation deficiencies for physicians in accordance with Federal, State, Hospital and Accrediting Body requirements; prepares documents for disclosure in accordance with Federal HIPAA, State and Hospital regulations and policies; Completes documents for State vital statistics within the State prescribed timeframes. Routinely interacts with the public and physicians. Competently performs the duties of a Health Information Management Technician I.

What you will do:

• Release of Information: On a daily basis, interacts with providers, clinical staff, and the public (patients, insurers, attorneys, State and Federal agencies, etc.) to accommodate requests for copies of patient information. Understands the release of information policies and associated Federal, State, and Hospital policies. Assists with release of information routinely and when on weekend rotation. Obtains appropriate release request document and verifies patient identity prior to release. Refers Amendment and Restriction requests to leadership. Accurately logs releases in CIOX’s or hospital accounting of disclosures/logging system. Efficiently prepares copies of requested in paper, CD, PDF, Fax and other approved electronic formats. Accommodates patient and physician requests within same day. Accesses Vail Health's various systems including its outsourced Cloud system to capture the documentation requested. Ensures only the minimum necessary is disclosed in accordance with HIPAA requirements and complies with policies that ensure the medical record retains its value as legal evidence. Routinely handles more than 70% of the Department’s monthly requests. May train others to assist with this function.
• Deficiency Analysis: For at least 70% of the monthly encounters, verifies the content of the medical record ensuring that patient identification matches on all documents. Reports discrepancies identified within a patient’s encounter to leadership. Abstracts data from the medical record for compilation of administrative statistics. Assesses the content of the patient record in accordance with Medical Staff Bylaws, Rules and Regulations, State, and Accrediting body requirements. Identifies documentation deficiencies and assigns to the appropriate provider. Annotates deficiencies. Monitors completion of those deficiencies. Identifies mis-scans and poorly scanned documents, reports on these findings and attempts to correct scanning errors. Recognizes and reports unusual circumstances and/or information with possible risk factors to appropriate risk management personnel and reports problems, errors, and discrepancies in dictation and patient records to leadership. Interacts with providers to obtain additional information required to complete and/or code the chart. May train others to assist with this function.
• Birth Certificates/Paternity: Collects information directly and indirectly from new parents to accurately and completely prepare birth certificates and related documents for State vital statistics within prescribed timeframes.