Team Leader HIM Data and Systems Medical Records

Department Job Description Summary

Team Leader, HIM Data & Systems (Medical Records)

• Leads daily HIM operations
• Serves as Epic super-user
• Provides training, onboarding, and workflow optimization for medical records processes
• Oversees chart deficiency management, data integrity, and complex chart corrections
• Ensures accurate EMPI maintenance and compliant documentation practices
• Acts as primary support liaison for system issues
• Coordinates chart reconciliation, document management, and physician deficiency follow-up
• Supports timely completion, coding, and release of information
• Ensures adherence to HIPAA, Joint Commission, and regulatory standards

Key Qualifications

• RHIA/RHIT preferred
• Associate’s in HIM
• 3+ years of HIM/acute care experience with strong Epic proficiency

Position Responsibilities

• Serve as the department's Epic super-user
• Provide hands-on training, onboarding new hires, and creating clear workflow guides for system updates
• Assist the Supervisor in EPIC HIM deficiency tracking and completion
• EPIC Hospital Chart completion process
• HIM Chart tracking protocol
• EPIC Chart correction process and Epic Identity
• Act as the primary support contact for Epic's end-users
• Identify issues in Epic WQ's as well as issues that impact other applications and communicate issues to Director, management team, and IT support to resolve them
• Drive efficient daily use of integrated Epic HIM workflow—including Chart Deficiency, and Identity (chart correction)—to streamline departmental operations
• Able to assess situations, resolve minor technical issues associated with EPIC/One Content WQ's; utilize basic IT troubleshooting processes with the HIM IT help for problem resolution where necessary to maximize efficiency and effectiveness
• Assist in Daily Chart Reconciliation & Workflow Coordination
• Monitor and log daily patient discharge lists to reconcile all incoming medical records, follow up on missing charts with clinical units, compile and distribute daily suspension and status letters, and assign staff tasks for document prep, scanning, and indexing into OneContent
• Enforce federal, state, and hospital policies regarding HIPAA, document retention, and chart completion timelines to prevent provider chart delinquencies
• Responsible and competent to answer any questions the physician/resident may have about their deficiencies in Epic or OneContent
• Serve as a backup for marking "patient deceased" in Epic when notification of death certificates are received by scanning supporting documentation in OneContent
• Create new forms in OneContent
• Responsible to analyze and resolve chart corrections cases in Epic, patient demographic overlays, merging patients and executing uploading/deleting of scanned documents or pictures utilizing Media Manager
• Ensure all chart correction, unmerge, and electronic merge processes adhere to HIPAA privacy regulations, Joint Commission documentation standards, and legal medical record requirements
• Resolve Contact Moves; Investigate errors where clinical data (notes, vitals, orders) was documented on the wrong patient or the wrong encounter
• Move the documentation to the correct record per policy
• Responsible to participate in internal audits on a monthly basis to ensure physician’s compliance with TJC and regulatory standards and guidelines related to medical records management by examining and gathering data to complete the forms, H & P and Discharge Summary audits
• Responsible to retire and/or administratively close charts in One Content and Epic from physicians who are no longer on staff
• Monitor physicians incomplete record activity, including notifying physicians of incomplete records until records are completed for release of information purposes and to assist coding staff obtain necessary clinical documentation for coding and reimbursement purposes
• Competent to answer any questions or concerns from nurses, residents, ARNP, PA's and physicians regarding deficiencies in EPIC/One Content and/or direct these individuals to the appropriate person for clarification
• Serves as a backup for deficiency tracking of Residents and Fellows and sends comprehensive report to Program Coordinators for all the services on a bi-weekly basis
• Analyze from the open, closed verification and cardiovascular work queues in Epic and promptly performs validation and reanalysis to ensure completion and removes deficiency from the EMR
• Actively communicates and encourage physicians to complete delinquencies in a timely matter
• Interacts and communicates with providers, and their office staff until completion
• Collaborates with Data integrity analyst and makes chart correction request after troubleshooting and triaging chart corrections requests

Benefits

• Health benefits
• Life insurance
• Long-term disability coverage
• Healthcare spending accounts
• Retirement plan
• Paid time off
• Pet Insurance
• Tuition reimbursement
• Employee assistance program
• Wellness program
• On-site housing for select positions and more!