HIM Tech II

About the role

Vail Health is seeking a Health Information Management Technician I to process medical records, identify documentation deficiencies, prepare documents for disclosure, and handle release of information requests.

Responsibilities

• 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.
• Routinely interacts with the public and physicians.
• Completes documents for State vital statistics within the State prescribed timeframes.
• 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.
• Affords assistance 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.
• Affords efficient preparation of copies of requested in paper, CD, PDF, Fax and other approved electronic formats.
• Affords accommodations for 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.
• Affords assessment of 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.
• Maintains monitoring of 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 prepares and submits birth certificate information in accordance with Colorado State Department of Vital Statistics.
• Affords assistance to patients in declaring paternity responsibilities.
• Interacts with the State as needed to address birth certificate data.
• Prepares at least 70% of the monthly birth certificates.
• May train others to assist with this function.
• Amendments/Restrictions: Accurately scans amendment or restriction documents to the medical record upon request from leadership.
• Work Queues: On a daily basis, reviews and rectifies those HIM Department work assignment queues, such as Outpatient, Inpatient, ED/Urg, Physician Orders, Imports transcribed documents and corrects errors, Pending Coding Cases, etc.
• Notifies the coders daily of the presence or absence of work in the queue.
• Other Projects: May work on special projects as required.
• Customer Interaction: Effectively engages with all customers.

Requirements

• Two years of Health Information Management Department experience required.
• Scanning and/or release of information experience, required.
• Experience working with the public in a customer service role required.

Qualifications

• Graduate from accredited school of Health Information Technology or Management, preferred.
• College graduate or certificate in other health related degree or certification preferred.
• Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) preferred.
• Medical Billing or Coding Certificate preferred.