Job Description

Job Description

Job Description

Description:

Mission of Department: To maintain quality healthcare records and to meet or exceed our customer expectations.

Purpose of Position: The Health Information Management (HIM) Clerk performs all ongoing activities within HIM related to the release and transcription of data. Also, performs all ongoing activities related to the assembly, analysis, and compilation of data from each individual patient encounter/record. Adheres to the organization’s policies and procedures covering the Health Information Management department and the processing of patient health records in compliance with federal and state laws and the healthcare organization’s information privacy practices. This position will be a temporary role with the potential to become full-time.

Essential Functions:

• Ensures receipt of all records of patients discharged from the hospital by reconciling with list of discharged patients or records associated to clinic and/or hospital patients.
• Scans completed hospital and clinic records into the electronic medical record, as required.
• Analyzes the chart, confirming all scanned documents have been scanned into the correct location, with the correct, date, time, and subject, per the naming conventions, and makes corrections/rescans, as needed.
• Purges and records and/or scans old records prior to destruction.

Non-Essential Functions:

• Transcribes dictation from physicians and other professional staff accurately and timely (48 hours or less), coordinating, as needed, with any outsource transcriptionist.
• Tracks completed transcription.
• Reviews for completeness of medical records of patients treated in the hospital inpatient and outpatient settings to facilitate timely coding, including for presence of history and physical within 24 hours, discharge summary, and progress notes, and prepares and provides outstanding documentation lists by provider for completion.
• Searches for any additional diagnoses in archived records, other encounter problem lists, or other encounter documentation, providing to coder/HIM Coordinator to consider any additional coding to abstract.
• Facilitates response to any Discern Notifications.
• Facilitates internal and external queries, as needed.
• Ticklers external queries and follows up weekly until response or until queries have been communicated in creative ways on at least three occasions.
• Verifies charge corrections have been made, and releases encounters only awaiting charge correction.
• Forwards any encounters with missing treatment authorizations to Registration supervisor.
• Coordinates Specialty Clinic schedules, ensuring that required documentation from the clinics are received in time for coder to code the encounter.
• Handles requests and inquiries for patient information, dispersing the information with accountability to all regulatory entities and according to the facility’s policies and procedures.
• Reviews for completeness of release of information requests.
• Compiles data from medical records for periodic and statistical reports.
• Maintains registers for statistical compilation (acute, skilled, intermediate, outpatient, emergency, death, transfer).
• Evaluates existing forms and their processes, recommending and implementing improvements to enhance efficiency and user experience.
• Designs, develops, and updates electronic and paper forms based on user requirements, ensuring clarity, efficiency, and consistency.
• Collaborates with various departments to gather requirements, solicits feedback, and ensure forms meet their specific needs and comply with organizational policies.
• Coordinates interdisciplinary forms committee meetings for review and standardization of new, updated, and deleted forms across departments.
• Maintains central forms database, ensuring all forms are properly version-controlled, updated, and accessible.

Other Duties:

• Assist with non-essential functions
• Assist with any other duties as the need arises.

The preceding functions have been provided as examples of the types of work performed by employees assigned in this job classification. Management reserves the right to add, modify, change or rescind work assignments and to make reasonable accommodations as needed. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skills and /or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Additional Responsibilities:

Education, Qualifications, Experience: High school graduate with computer experience and or keyboarding skills. Related office experience may be substituted for one to two months of on-the-job training. Three- to six months of on-the-job training may be provided to become familiar with clinic and hospital record keeping system and to comprehend pertinent medical terminology.

Personal Characteristics: Initiative, tolerance, adaptability, motivated, positive regard for others, objectivity, self-assessment, analytical, flexible, able to interrelate with others, willing to learn, assumes responsibility, does not wait to be told what to do and how to do it, inquisitive, accepts individual challenges, adaptability, listens effectively, gives clear directions, good judgment and decision-making skills, analytical thinking, ability to summarize, probe and clarify.

Knowledge, Skills, and Abilities:

• Word processing applications
• Verbal ability is required to read and understand medical terminology, and understand written reports, and to abstract pertinent information from records
• Numerical ability is required to compile, interpret, and utilize statistical data
• Clerical perception is required to spot pertinent detail in material and to avoid errors in computation

Equipment:

• Computer/printer
• Copy machine
• Fax machine/phone
• Transcriber
• Ten-key calculator

Expectation of Service: This is a non-exempt 40 hour per week position. Regular and punctual attendance is required.

Physical Requirements: This position requires continual sitting and typing at a computer terminal, some walking, bending, stooping, and lifting of up to 25 pounds. Must be able to read, write, hear and understand electronic verbally transcribed information.

Scott County Hospital is an equal-opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristics as outlined by federal, state, or local laws.

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