HIM Technician II

SUMMARY:

Assures complete and accurate maintenance of key patient data in the Electronic Medical Records (EMR) information systems. Understands how the various registration and clinical systems interface to trouble-shoot and determine the appropriate course of action when errors are identified. Exercises a high degree of responsibility, problem-solving ability, analytical skills, initiative, and good judgment in resolving duplicate patient records and missing or erroneous data in patient records, including both the EMR and the paper record.  Will assist in the evaluation of quality and productivity metrics.

ESSENTIAL FUNCTIONS:

• Reviews and identifies discrepancies and omissions of information in various patient records in accordance with the Chart Correction Policy; communicates discrepancies to the appropriate system contact or responsible individual and tracks through resolution. 
• Ensures correct documentation for continuity of care and record keeping practices.
• Identifies, corrects and records errors scanned into the system then, educates staff on documentation.
• Analyzes clinical & demographic information to accurately identify and resolve edits, duplicate, Master Patient Index (MPI) entries and patient overlays.
• Determines and resolves errors in patient data that cause a transaction in the information system(s) to fail, preventing clinical information to be appropriately available for patient care.
• Reviews, research, and edits master patient index information daily. 
• Resolves fatal edits or warnings (caused by mismatched master patient index data elements in registration and clinical systems) received from registration or clinical systems daily. 
• Reviews hard copy and electronic patient information to determine if information is similar or dissimilar and take the appropriate action.
• Identifies and corrects duplicate patient records across all information systems, including the merge of patient information (clinical, financial and appointment information). 
• Researches and resolves complex issues of patient identification.
• Handles registration errors and correction, including notification to management of the registration area creating error. 
• Communicates cross-departmentally and assists physicians and/or clinical staff with resolving errors within the EMR.
• Reviews daily reports for duplicate medical record numbers, errors in consecutive issuance of medical record numbers and overall integrity of daily additions to the MPI’s.
• Reviews requests for clinical system access in accordance with established policy.  Establishes/revokes system access codes within established guidelines.
• Assists with testing upgrades or new systems in relation to data integrity and merging of clinical information.
• Assists in training new personnel in indexing, identity management, and policies and procedures.
• Assists in quality assurance review of various workflows in the department.
• Exhibits excellence in customer service through appropriate attitude and interaction with all patients, visitors, and staff.
• Assist in developing, supporting, and maintaining workflows in the department.
• Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication. 
• Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards.

·         Performs related duties as assigned.

MINIMUM QUALIFICATIONS:

EDUCATION: High school diploma or general education degree (GED) required.  

EXPERIENCE: Two (2) years of related records management experience.

LICENSURE OR CERTIFICATION: None required; RHIA/RHIT preferred.

KNOWLEDGE, SKILLS, AND ABILITIES:

·         Knowledge of medical records review needs, medical terminology, and coding.

·         Knowledge of federal, state and hospital institutional policies and procedures for maintenance of medical records.

·         Skill in the review of medical records to ensure quality of coding and record management.

·         Skill in the use of computer applications and programs specific to HIM and Microsoft Office Products.

·         Ability to train others in the proper use and application of computer programs.

·         Ability to read, analyze and interpret business periodicals, professional journals, technical procedures, or governmental regulations.

·         Ability to prepare and write reports, business correspondence, and procedure manuals.

·         Ability to develop and present information in a clear and concise manner.

·         Ability to respond to inquiries or complaints from employees, patients and/or their representatives, and the general public.

·         Ability to define problems, collect data, establish facts, and draw valid conclusions.

·         Ability to interpret an extensive variety of technical instructions in mathematical or diagram form, and deal with several abstract and concrete variables.