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CLINICA DE SALUD DEL VALLE DE SALINAS

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HIM Technician

Open 31d

Job Summary: Reviews medical records after discharge for completeness in compliance with the health facility’s policies, accrediting organization standards, federal and state requirements. Assures that patient abstracts are correctly entered into the medical record deficiency system.

Collects all discharged patient medical records on a daily basis.

Prepares medical records and collects loose filing for those discharged medical records for scanning, matching batch header sheets, does quality review, uploads and accepts batches for completeness.

Scans and indexes health and administrative information received daily into the health facility’s electronic health record system within established timeframes

After all information is scanned and indexed, files or destroys the paper files, per policy and procedure.

Prepares ED, hospital, and consultant records for scanning: removes staples, places batch header sheets with appropriate medical record and organizes medical records in an orderly manner; assists in a total complete record.

Interact closely with the Information Technology Department when discrepancies occur involving the computer system which affects the electronic health record system functions.

Maintains an error rate of 5% or less in scanning medical information into the electronic health record system.

Combines current patient medical record with any previous patient discharges, if applicable.

Assists in quality audits to ensure the integrity of scanned images into the electronic health record system.

Places assembled medical records in proper folder according to medical record number and scans them into the Electronic Health Record (EHR).

Analyzes medical records of discharged patients for completeness and accuracy according to department and health facility policy and procedures.

Monitors deficiencies in the electronic health record that require physician completion.

Forwards all analyzed medical records to the Coder.

Responsible for coordinating the release of medical information to all requesters, including patients, physicians and other healthcare providers.

Verifies authorizations in accordance with health facility policy and procedures and state and federal laws.

Responsible for maintaining security and confidentiality regulations for record access and review. Consults director or supervisor of any unusual request.

All requests for records are stamped with date received and logged in the correspondence computer.

Prepares request for information to be copied by copy services, meeting established guidelines. And notifies requester when records are available

Maintains supply closet and orders supplies as necessary.

Perform performance improvement audits on each medical record through data collection and documentation review as directed by the director

Assists in answering telephone and taking accurate messages.

Is familiar with pediatric and OB/GYN medical record requirements.

Maintains health facility requirements, policies and standards on confidentiality.

Assists in retrieving medical records for physician completion, as applicable.

Accepts additional assignments and completes them within a designated timeframe.

Must be able to keep up with workload.

Maintains a good working relationship within the department and other departments.

Protects the confidentiality of patient information, as well as access to computer files and access codes.

Supports and maintains a culture of safety and quality.
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