Summary 

The Health Data Technician maintains medical records operations by following policies and procedures; reporting needed changes. Assists HIM Operations sections in release of information, prepping, scanning and indexing, analysis, and Birth/Death Registry with processes and procedures to comply with CRH policies, State and Federal policies, HFAP and HIPAA Statutes. 

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 CRH. 

Essential Duties and Responsibilities  

Birth/Death Registry 

Ensure the Birth/Death Registry meets all statutory functions and guidelines as related to births, deaths, and fetal deaths 

Birth Registry 

Assure all live births are recorded as required 

Identify newborns and interview parent(s) for birth certificate information 

Assure birth certificates are signed by the physician/Director and delivered to the Health Information Management department in a timely manner 

Interview parents and complete Acknowledgment of Paternity forms. All supporting documents are mailed weekly to Virginia Paternity Establishment Program 

Enter completed birth certificates into the Virginia Department of Health Vital Records System and mail the paper certificate to the Office of Vital Records, Division of Health in Richmond, Virginia 

Complete Birth Verification Forms as requested 

Use the Department and State’s Birth Registry Computer System in an effective and proficient manner 

Quality 

Perform Quality on ALL birth worksheets for state statistical purposes 

Work with nursing to establish correct clinical data for statistical purposes 

Acknowledgement of Paternity 

Establish the paternity of the child by providing legal documentation to be completed by the father of the child to determination paternity; mail all supporting documents to VVEST on a weekly basis. 

Provide services to establish paternity at the local correction facilities. 

Ensure all state and federal laws of establishing paternities are met.  

Death Registry 

Complete fetal, newborn, inpatient and ambulatory death certificates 

Complete the State Fetal Death Report and the hospital’s Death Report 

death certificates with funeral homes in Virginia, North Carolina, and across the United States 

Compile statistical data for management reporting, budgets and surveys 

Actively participate in service recovery and customer service activities to ensure a superior customer contact 

Adhere to CRMC's confidentiality policy for all information related to patients, family and friends, hospital employees, physicians and clients 

Maintain effective interdepartmental communication 

6. Release of Information 

a. Responsible for the release of confidential information to authorized sources.  This is a very sensitive position that requires extensive knowledge of legal requirements and policies and procedures dealing with release of confidential information. 

b. Ensures all authorizations met the federal criteria for medical/surgical and psychiatric/substance abuse/AIDS/Hepatitis authorizations.  This includes ensuring each and every request is valid according to federal and state criteria. 

c. Interacts with requestors to identify medical records needed for patient care, review, billing, or release of information.   

d. Performs self-quality checks on all work to assure accuracy of the release, confidentiality, proper invoicing and reconciliation. 

e. Handles all requests and inquiries of patient health information whether received via mail, fax, phone or in-person.  Verifies the patient identity and confirms the authorization is valid.  Ensures the requesting party has a legal right to request a patient’s medical information. 

7. Operations  

Prepping Documents 

Reconcile the paper medical records with the hospital census to verify receipt of all records. 

           Confirm the patient name, medical record number, and account number on every page in the chart, front and back. Add patient                     stickers to any forms missing demographic information.   

Examine the quality of each page and stamp illegible documents with the “Poor Quality Original” stamp. 

Ensure all pages are in the same and proper direction. 

Repair forms as needed such as torn, wrinkled, folded and dog-eared pages.             

Remove all staples and paper clips. 

Identify and separate multi-part forms with the original being kept. 

Separate and sequence perforated forms making sure the correct separator sheets are included with each section of the chart for scanning process. 

Revise non-standard documents so they can be processed by the scanner (tape small paper or post-its onto letter size paper). 

Print cover sheets for the proper patient and account number and add them to the chart to create a batch. 

8. Analysis 

a. Prepare certified letters of notification to physicians for delinquent medical records 

b. Scan requested/missing documentation into chart (H&P’s, consults, studies, etc.) 

Summary of Other Job Duties and Expectations 

Adhere to the Service Excellence Standards and Expectations at Chesapeake Regional Medical Center 

Exhibit excellent customer relations to patients, visitors, physicians, and co-workers 

Exhibit courteous communication skills and an ability to work with others, exercising good judgment in performance of job duties 

Demonstrate courtesy, compassion, and respect to others in adherence of the hospital's philosophy and policy for promoting  positive work and customer environments 

Work as a team to continuously improve work quality 

Demonstrate a commitment to flexible work schedules when it is necessary to ensure patient care 

Present self in a positive manner as reflected by personal attire and etiquette 

Attend required hospital-wide orientations, meetings, and in-services 

Qualifications 

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Education and Experience  

Minimum Required Education: Associate degree in Health Information Technology 

Experience: 3+ years' experience in an acute care setting and a strong knowledge of medical record content and forms for inpatients and outpatients is required 

Certificates, Licenses, Registrations  

RHIT certification is preferred.