Position Summary: Under the direction of the Director of Health Information Management, independently provides physicians/providers with incomplete record data; verifies completion of records by physicians; performs record keeping and statistical data; serves as the primary liaison between the Health Information Management Department and the medical staff members, uses good communication and customer service skills; uses professional and ethical judgment and critical thinking when performing their duties; uses equipment, material and systems according to policies, procedures, and practice standards; performs duties using appropriate professional and ethical behavior.

Responsibilities:

Verifies documentation is present and records deficiencies.  (Performance is measured by provider feedback and random chart audits) Reviews records, identifies unapproved forms and notifies management. Provides monthly statistical data concerning timeliness of physician documentation and record completion.  Updates incomplete record data deficiencies Provides daily phone support screens and directs callers to appropriate individual. Ensures (and also, performs) provider’s records are complete; notification to provider on a weekly basis; and follows up to make sure record has been completed. Receives request for medical records; verifies appropriateness of request, identifies record and prints for requestor.  Verifies discrepancies in dictation. Reviews, compiles and submits statistical data by provider and/or work type, etc. concerning the quality of the dictated, transcribed, edited and self-edited reports. Assists in managing transcription/dictation issues by investigating and finding solutions; gathers sufficient information to make an informed decision; and investigates all options and their consequences and makes timely decisions. Maintains appointment calendar for direct report and schedules and confirms meetings and appointments, coordinates meetings as needed including room scheduling, notices, special event requests and preparation of necessary documents; attend various committee meetings as assigned and takes and transcribes minutes as directed; develop and maintain an effective filing system.

Qualifications: 

Required:

Previous transcription/editing experience required Must be proficient with computer and keyboarding and willingness to learn necessary computer skills and software; good at spelling, punctuation, grammar, and oral communication; good customer service and interpersonal skills, must be tactful in their dealings with people; discretion, good judgment, organizational or management ability, initiative, and the ability to work independently.

Preferred:

Associate degree in health information management Advanced knowledge of anatomy and physiology, disease processes, sign and symptoms, medications, laboratory values, and medical terminology courses Previous medical office experience Registered Health Information Technician (RHIT) certification Certified Medical Transcription (CMT) certification preferred; and additional certification may be required for certain patient care settings or populations. Specific information and the timeframe in which such certification must be attained will be provided by the department director/manager/supervisor at time of hire/transfer into department.

Infection Control: Initial and Ongoing training in dealing with infection control. Trainings could include but are not limited to, blood borne pathogens, bodily fluids and bio hazardous materials as it applies to your daily work environment.

Patient Interaction: No Contact

HIPAA: This position will have access to the following Protected Health Information in order to carry out the duties related to their position at Hays Medical Center based on the following criteria:
Primary – required (routine) to do the job;
Secondary – required for the job, but mostly be exception; and
None – no approved access

Description of Information
Primary:
Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status, Religion

Clinical Information (information that describes a patient’s health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical

Coding Information (clinical information that is in (alpha) numeric format): ICD-9 Codes, Rev Codes, CPT Codes

Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information, Payment Rates