HIM Technician II

Responsibilities

• Reviews medical records for completeness in compliance with hospital’s bylaws, HFAP standards, federal and state requirements.
• Provides data support by performing medical record reviews and data entry, creating and maintaining spreadsheets, databases and data collection forms.
• Compiles results into reports and graphical presentations and performs data verification, validation and reporting to required external reporting agencies.
• Filings required information into proper medical record.
• Assembles patient medical records to release upon consent of patient or as allowed for treatment, payment and healthcare operations, and releases records according to policy.
• Immediately notifies HIM Manager if records have been disclosed inappropriately.
• Retrieves old records from previous EHR and scans or sends to requestor.
• Analyzes medical records for completeness and accuracy according to department and hospital policy and procedures.
• Enters deficiencies into computer and keeps a current log of those deficiencies.
• Performs audits as part of performance improvement on medical records when directed by the HIM Manager.
• Auxists in answering telephone and taking accurate messages.
• Maintains hospital requirements, policies and standards on confidentiality.
• Auxists in retrieving medical records for physician completion and obtains signature if needed.
• Possibility of on-call hours.
• Completes all birth certificates and death certificates, which includes entering the data into the state website.
• Accepts additional assignments.
• Completes all assigned tasks within the allotted time frame.
• Keeps up with workload and processes a minimum of 20 medical records per day.
• Trains other software interfaces for maintaining a complete medical record.
• Maintains a good working relationship within the department and other departments.
• Complies with OSHA standards and universal precautions.

Qualifications

• Prefer associates degree in Health Information Administration or Technician, licensed nursing training or equivalent health care program.
• Preferred: Two or more years of previous similar hospital or clinic experience.
• Preferred: Knowledge of HFAP standards and state medical record requirements.
• Preferred: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) preferred.
• Prefer familiarity with medical record requirements of Nebraska and CMS.