Health Information Rep Lead

Major Responsibilities:

• Partners with leadership to provide training, technical expertise and guidance on all HIM workflows. Uses strong communication and critical thinking skills to identify, investigate, and escalates issues as needed. Monitors department workflows and provides guidance on complex issues. Collaborates across the system HIM department and professionally interacts with other departments to accomplish goals. Makes recommendations for process improvement. Advises staff on procedural changes and completes projects as assigned by management.
• Supports Revenue Cycle by analyzing and identifying missing documentation elements needed for physician and hospital coding. Ensures compliance with State and Federal regulations, such as Det Norski Veritas (DNV) or The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), all Medical Staff Bylaws and organizational policies. Collaborates with Clinical Informatics, Revenue Cycle Trainers, and various department leadership to identify system problems or front end workflow issues, and to provide educational opportunities to clinicians, providers and team members as needed. Serves as point of contact for record completion support for clinicians and other providers.
• Applies knowledge of medical terminology and nomenclature to accurately identify documentation needs based on patient service areas and level of service provided. Assigns, edits, and tracks medical record deficiencies by responsible provider into chart management system accurately and timely following established policies and procedures.
• Provides support and education to clinicians and providers regarding record completion activities. Verifies accuracy of physician deficiency and suspension status in the electronic health record. Supports activities for accurate reporting of physician delinquencies for the suspension process. Accurately sends delinquency and/or suspension notifications to clinicians and physician leadership.
• Receives, collects, sorts, prepares and scans internal and external clinical documentation into the EHR according to HIM procedures. Sorts and measures incoming and remaining scanning to accurately track volumes and turn-around times in the system-wide database. Monitors system volumes and TATs to distribute work across the system HIM department and prevent backlogs. Investigates and corrects questionable scans and regularly maintains error work queues.
• Utilizes medical terminology and nomenclature to accurately classify clinical documentation for all tests, treatments, procedures, and other services. Confirms that patient records are scanned correctly to the patient, document type, encounter or order in a timely manner. Ensures clarity, legibility and position of the scanned documents is readable by the end user or indicates best quality. Uses critical thinking and problem solving to make corrections and/or edits according to Health Information Management policy.
• Assists leader with documentation quality assurance reviews. Provides timely results to leadership and assist with education and re-training. Completes timely error corrections; including deleting images, re-scanning and re-indexing/appending documents appropriately. Assists leadership with privacy investigations.
• Accurately abstracts patient information discretely into the EHR to ensure clinical notifications and alerts are present for all clinical team members appropriately. Analyzes documents for validity and generates letters to patients as appropriate.
• Partners with leader to review team member productivity, report production rates, and assist team members in achieving performance expectations. Assist with scheduling and timecard edits as needed. Serves as a subject matter expert and participates in upgrade testing. Assists in system-wide initiatives, projects, and performs other duties as assigned.
• Assists patients, visitors and internal and external customers as appropriate in person or via telephone in a prompt and courteous manner. Ensures maintenance of equipment and works to resolve malfunctions and/or poor image quality. Receives and processes continuing care requests in accordance with AAH release of information policies and procedures and any applicable legal regulations. Properly manages the destruction of all qualified records according to retention guidelines and policy.

Licensure, Registration, and/or Certification Required:

• None Required.

Education Required:

• High School Graduate.

Experience Required:

• Typically requires 2 years of experience in Health Information Services or related field, or experience as a Health Unit Coordinator or Medical Assistant.

Knowledge, Skills & Abilities Required:

• Proficient computer and keyboarding skills with the ability to learn new computer software systems such as Epic, OnBase, Microsoft Office and legacy archives.
• High attention to detail and accuracy with frequent interruptions.
• Ability to prioritize workload and work under pressure in a fast-paced environment with time constraints.
• Ability to work independently and make decisions with minimal supervision while maintaining quality and productivity standards.
• Strong customer service, interpersonal and communication service skills.
• Works collaboratively in a diverse team environment with openness and respect to learn, create and problem solve.
• Ability to give and receive constructive feedback and take personal ownership for success.
• Ability to adapt to a fast-paced environment and transition to switching tasks without issue while maintaining quality and accuracy.
• Ability to safeguard protected health information (PHI) and possesses basic knowledge of HIPAA.

Physical Requirements and Working Conditions:

• Ability to proficiently operate all equipment necessary to do the job: fax, multi-phone line, copy machine, etc.
• Must be able to sit, stand, walk to perform rounds in time allotted, squat, twist/rotate, bend and reach for prolonged periods of time in order to complete required word processing, filing, photocopying, and distribution of materials and other related functions.
• Requires team member to walk a moderate/significant distance throughout medical center to retrieve records. May require the ability to push/pull a records cart.
• Ability to perform repetitive functions and hand movements in a normal office environment.
• Ability to lift, push and pull items weighing up to 20 lbs.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.