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Description POSITION TITLE : HIM Technician II DEPARTMENT: Health Information Management EMPLOYEE REPORTS TO: Medical Records Director or CEO SUPERVISES: N/A FLSA STATUS: Non-Exempt EMPLOYMENT STATUS : Full-time, Part-time, or Per Diem DESCRIPTION OF POSITION This job description is a record of the essential functions of the listed job. The job description provides the employee, CEO, Human Resources, applicants and other agencies with a clear understanding of the job, where it fits into the organization, and the skill and work requirements in relation to other jobs. Jobs are always changing to some degree and the existence of the approved job description is not intended to limit normal change and growth. The facility will make reasonable accommodations to otherwise qualified individuals who are capable of performing the essential functions of the job with or without reasonable accommodation. POPULATION SERVED The position has minimal direct patient and family member(s) contact for a population of patients ages 18 and older. Good customer service skills are required to serve this population. Specialized training for age- specific population is not required. POSITION SUMMARY The HIM Technician II will primarily be responsible for the release of information, concurrent and retrospective assigned audits for chart completion, assisting the Director in processing medical staff files, MEC meeting preparations and other duties as assigned by the Director of Medical Records. He/she must at all times safeguard and protect the patient’s rights to privacy by ensuring that only authorized individuals have access to the patient’s medical information and that all release of information are in compliance with the request, authorization, company policies and HIPAA statues. Additionally, he/she is required to maintain a professional health care office environment on a day-to-day basis, working with confidential and personal health information in a conscientious manner and providing patients and other requestors with the appropriate level of service. This position engages in direct customer service and must perform duties and conduct interpersonal relationships in a manner designed to project a positive image of the department and hospital. The HIM Technician II will work with the HIM Director and members of the department to promote a harmonious work environment. Requirements POSITION QUALIFICATIONS The position requires a minimum of a High School Diploma, an Associate’s Degree is highly preferred, a minimum of 2-5 years’ experience in a Hospital or physician office setting within HIM department. Electronic health record experience preferred. Completion of a medical terminology course with a solid working knowledge and overall understanding of the healthcare environment. Ability to know, understand and apply federal and state regulations and departmental policies and procedures. Strives to obtain and maintain accurately tracked data. Effective time management of daily tasks and duties with good organizational and quality focus skills with a problem solving, critical thinking mindset. Strong data entry skills necessary; type a minimum of 35 words per minute, competent use of email, fax machines, scanners and copiers, Word and Excel application skills are required. Good customer service skills with a respectful and positive attitude. Excellent communication skills, both orally and written. DUTIES AND RESPONSIBILITIES • Responsible for the day-to-day operations of Health Information systems (Electronic medical record etc.) to include workflow management, monitoring of queues/print/ fax servers/security and archiving for both internal and external customers. Responsible for functional system operations to include training, support and troubleshooting and working queues as assigned within the HIM applications/systems. • Provide excellent customer service by being attentive and respectful; insures understanding of customer request and follows-through as promised; proactive in identifying and immediately communicating any concerns or problems to HIM Director. Helps resolve customer service matters in a professional manner. • Interacts with requestors to identify medical records needed for patient care, review, billing or release of information per minimal use standards. • Handles all requests and inquiries for patient health information whether received via mail, fax, phone or in-person. a) Access computerized patient record. b) Verifies the patient identity and confirms that the authorization is valid c) Ensures the requesting party has a legal right to request a patient’s medical information. • Prioritize release of information requests, retrieves medical records, active and inactive and delivers records in accordance with established departmental procedures. Responsible to accurately track all incoming requests upon receipt and upon completion of all requests on the electronic PHI log. d) Process the request within established departmental procedures. • Performs at established quantitative and qualitative work standards on all patient chart audits, concurrently and retrospectively, to meet departmental goals and objectives; maintains accurate data audits and current data tracking sheets on a daily basis. • Analyzes, monitors and maintains chart completion by clinicians and physicians through accurate and efficient chart review per established processes. Effective and timely communication with physicians and evidence of appropriate measure to avoid total medical record delinquency that equals to exceeds twice the average monthly discharge rate. • Performs self-quality checks on all work and job tasks to assure the accuracy of audited, collected data and the confidential handling and release of patient information. • Prepares, maintains and submits all assigned reports in an accurate and complete manner meeting all deadlines • Assists with processing of medical staff files and MEC meeting preparations. • Promotes quality improvement, staff and patient safety, and cultural diversity through department operations and by personal performance. • Maintains current knowledge related to applicable statutes, regulations, guidelines and standards necessary to perform job duties in accordance with the requirements of the departmental policies and procedures. • Handles, assists and/or direct incoming calls for the department as per policies and procedures. • Other duties as assigned by HIM Director. DEMANDS AND CHARACTERISTICS OF WORK, EQUIPMENT USAGE, AND WORK ENVIRONMENT PERCENTAGE OF WORK TIME 1-33% 34-66% 67-100% Standing/Walking 67-100% Sitting 67-100% Twisting 67-100% Lifting/Carrying 1-33% Pushing/Pulling 1-33% Climbing (Ascending/descending) 1-33% Bending/Stooping 1-33% Using arm muscles frequently or for extended periods 67-100% Using leg muscles frequently or for extended periods 67-100% Using back muscles frequently or for extended periods 67-100% LIFTING REQUIREMENTS – Individuals in patient care positions are required to lift a patient with or without assistance. 2-10 Pounds 1-33% 11-20 Pounds 1-33% 21-30 Pounds 1-33% 31-40 Pounds 1-33% 41-50 Pounds 1-33% 51 Pounds or More 1-33% WORKING ENVIRONMENT Working in hot, cold, wet surroundings 1-33% Working outdoors 1-33% Working with or near chemicals 67-100% Working near radiation sources 1-33% Potential exposure to communicable diseases 67-100% Working with hazardous waste materials 67-100% Utilizing essential upgraded or adaptive equipment as industry standards require 67-100% Using hand tools 1-33% Potential for cuts and bruises 1-33% EXCHANGE OF IDEAS Ability to express or exchange ideas 67-100% Ability to understand communication of others with or without adaptive devices 67-100% Ability to perform basic math 67-100% Ability to read at a secondary level 67-100% WORKPLACE BEHAVIORS I. RESULTS ORIENTATION – Meets current objectives and positions the organization for future growth. Completes daily tasks and assignments and processes large volumes of work associated with the operation of the department. II. SOCIAL SENSITIVITY - Builds positive relationships based on respect for others. Demonstrates a helpful, positive attitude. Maintains effective communication with peers, medical staff, patients, visitors, and families. III. QUALITY OUTCOMES – Meets and exceeds expectations of internal and external customers. All organizational and departmental standards regarding quality of performance are met. Demonstrates a strong commitment to confidentiality. Participates in quality improvement programs as directed. IV. SAFE WORKING ENVIRONMENT – Demonstrates an awareness of and adherence to safety and legal requirements established at the facility with an emphasis on maintaining a safe environment for all persons working in the facility. A. Accident/Injury Reporting – Reports any accidents, injuries, and unsafe equipment and conditions to supervisor by the end of the shift and reports any pre-existing conditions as identified by the ADA. B. Unsafe Conditions – Immediately reports and corrects, if possible, unsafe conditions or equipment. C. Workplace Standards – Compiles with relevant regulations, standards and policies governing safe workplace environment (OSHA, Accreditation, etc.) D. Safety Techniques – Maintains current knowledge of all aspects of the facility’s safety program by attending safety-related training as mandated upon hire and thereafter as required by facility. E. Modified Work – Accepts modified work assignments after receiving the physician’s release to return to work following an accident/ injury. F. Follows Prescribed/Recommended Treatment – Follows the prescribed/recommended treatment given by treating physician(s) after an accident/injury. V. EDUCATION – Participates in required in-services and educational programs on an ongoing basis. VI. ATTENDANCE AND PUNCTUALITY – Follows all facility guidelines outlining standards of attendance and punctuality. Responsible for reporting to and completing work at assigned times. UNIVERSAL PRECAUTIONS Universal precautions will be observed in order to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials. All blood or other potentially infectious materials will be considered infectious regardless of the status. The category shown below is designed to communicate the risk of exposure for this particular position.