**Employment Type:** Full time **Shift:** Day Shift **Description:** I Accountability Objectives: Responsible for multi-functions of Medical Records within the HIM department, as it relates to paper and electronic information. Retrieval, review, assembly, analysis, coordination, dissemination, monitoring, reporting, and verification for accuracy and completion, using SJM-O policies procedures and guidelines from multiple regulatory agencies (JCAHO, Department of Public Health, State and Federal laws, etc). Responsible for the integrity, completeness and confidentiality of health information. II Position Qualifications: Minimum Education, Licensure / Certification and Experience Required. A. Education + High School Graduate or GED equivalent. B. Licensure / Certification + Registered Health Information Technology certification or certification eligible preferred. C. Special Skill / Aptitudes + Excellent customer service orientation skills necessary in order to deal effectively with various levels of hospital personnel, outside customers and community groups. + General HIM Skills: excellent computer systems skills, preferably in a Windows environment. Experience with Healthquest, Cerner PowerChart/Profile, Vista, TDS Lite and/or Ascent Capture Batch Manager preferred. + Organizational Skills: excellent office organizational skills to include accurate filing skills, typing 45 wpm, and comprehensive knowledge of medical terminology. Must be detail-oriented. + Decision Making Skills: Ability to analyze and accurately interpret record documentation, exercising appropriate judgment. Minimal understanding of Release of Information policies in order to provide information for continuation of patient care. + Time Management Skills: Able to work independently with minimal supervision. Ability to function in a fast paced and challenging environment while demonstrating appropriate judgement. + Ability to pass hospital medical terminology assessment test prior to being considered for the position. D. Experience + Either a minimum of one year experience in a hospital or medical office setting with responsibility for maintaining and managing medical records including a basic understanding of Release of Information, Birth Certificate and chart processing,- OR - + Registered Health Information Technology (RHIT) certification or certificate-eligible, normally achieved by successfully completing two-year college level course work in an RHIT program. + Previous experience with data analysis preferred. + Knowledge of Medical Terminology. + Experience with computer systems/Windows platform. III Duties / Responsibilities: + Retrieve medical records throughout the hospital as directed, verifying receipt of record against daily discharge reports. Complete "Notification of Chart Not Available for Pick-Up" for unaccounted discharges following guidelines, follow up and priority processing. In transcription area, will perform minor editing of transcribed reports, utilizing medical terminology, grammar and language skills. Understanding of DNFB (Discharge Not Final Billed) and work with coding management to assure chart(s) are all accounted for in regards to billing and coding purposes. + Prepare records for scanning process of all batch types by determining completeness and accuracy as defined by the medical staff bylaw, rules and regulations, as well as other regulatory agency guidelines. + Answer phones and assist with customer inquiries, including but not limited to patient information. + Answer fax requests from outside agencies (i.e. Insurance companies, offsite facilities, etc.) Research and obtain requested billing information, medical records, and/or advance directives for various customers. Informs requestor of medical record status. + Perform quality control check by reviewing each page prepped and scanned correctly and patient identifier is appropriate to encounter. Review includes analyzing scanned images in PowerChart/Profile; adding physician signature lines and required deficiencies. Authenticating scanned images based on signature completion. In transcription area, will perform minor editing of transcribed reports, utilizing medical terminology, grammar and language skills. + Research patient information utilizing department computer systems, track the patient's record, input appropriate information to enable the physicians to complete the record and maintain/control the information, print information as requested. In transcription area, will import transcribed reports from outside services, copy, sort, & distribute reports. Utilizing department computerized systems, create media on historical records received from offsite facilities following established procedures for HIM. + Serve as a resource for clinicians in the record completion process and any other hospital-authorized personnel. This includes the retrieval and delivery of records and/or documentation to the clinicians. Assist physicians with the use of PowerChart. + Maintain specific documentation (i.e. Discharge Logs, Chart Requests, and Patient Care Requests), ensuring correct and complete information. File paperwork according to retention policy. + Perform periodic and random audits requiring immediate research and retrieval including third-party payer, clinicians, physician/residents and research departments. Purge paper charts that have been scanned 90 days after discharge date. In transcription area, will add/delete physicians from transcription/dictation systems and ensure outside transcription services are aware of these changes. Distributes copies of record documents to physicians as appropriate via mailboxes, fax or US mail. + Assist the department secretary with the No Admit/No Bed list, stuffing envelopes into mailing and faxing categories (internal, external). + Serve as a resource for the department on releasing patient confidential information appropriately and within the regulatory guidelines. Assist "Release of Information" when needed by contacting the physician for completion of record. Contact physician for authorization to release Behavioral Health records. + Resolve outstanding issues on various Profile deficiency reports including pending dictations report for fax blast. Analyze data as assigned. + Perform accurate and timely completion of Birth Certificates. Certify and Notarize Birth Certificates and Affidavits of Paternity. Electronically submit the completed documents to the State of Michigan. Serve as a resource to Nursing staff and patients regarding the legal definitions of Fetal Deaths and Live Births and apply this knowledge to the preparation of such documents. + Record and report weekly productivity stats. + Attend staff meetings and maintain awareness of department policies as they relate to departmental operations. + Conduct other duties requested by supervisor or management. + Demonstrates and actively promotes an understanding and commitment to the mission of St. Joseph Mercy Oakland through performing behaviors consistent with the Trinity Health Values. + Maintains a working knowledge of applicable Federal, State, and Local laws and regulations, the Trinity Health Organizational Integrity Program, including the Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behaviors. + Supports and conducts one's self in a manner consistent with customer service expectations. **Our Commitment to Diversity and Inclusion** Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law. Our Commitment to Diversity and Inclusion Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions. Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity. EOE including disability/veteran