Health Information Tech 1

Essential Job Functions

• Retrieves discharge records from the appropriate units on a daily basis.
• Analyzes records for completion, dictation, orders, signatures, charting to ensure complete documentation and in compliance with guidelines.
• Verifies all miscellaneous reports are filed in the medical record as well as ensuring that every document is accurate with the correct patient and information.
• Manages the patient identity by ensuring merges are managed in the EMR. Identifies and merges duplicate medical records and charts.
• Maintains a sign out system for records that are incomplete or need to be signed out.
• Assists in pulling charts for audits, requests from other departments or providers.
• Films medical records. Retrieves files from areas when needed.
• Follows all organizational and department policies. Sorts and opens the mail. Reviews incoming mail and correspondence. Answers phone in the department.
• Provides professional customer service and responses in phone, personal or through electronic communication. Review correspondence and forward if needed to other departments.
• Completes work assignments on time and willing to be a team player.
• Coordinates the release of medical records to insurance companies, lawyers, state and federal agencies, patients and other providers within the policies and guidelines established.
• Maintains confidentiality of all hospital and patient information at all times. Follows HIPAA regulations and policies.
• Communicates with patients, physicians, families and co-workers in person and on telephone.
• Provides professional customer service and responses in phone, personal or through electronic communication.
• Regular and predictable attendance is an essential job function.
• Ensures Patient Rights are followed as outlined in HIPAA; Patient Right to Amend the medical record, Patient Right to Restrict the medical records, Patient Right to view the medical record.
• Processes Birth Certificates and filing of paternity affidavits in accordance with the State and hospital guideline.
• Manages the missing documentation work list or work queues.
• Assists physicians/providers in chart completion or reanalysis by clarifying deficiency or explaining the chart completion process in the electronic record/paper record.
• Sets up and maintains the sign-out system.
• Assigns documentation deficiencies to the correct clinical staff.
• Performs medical record audit, identifying patterns and trends as needed.

Minimum Qualifications

• A high school diploma or equivalent.
• Knowledge of HIPAA preferred.
• Experience with medical records within a healthcare setting preferred.