HIM Operations Specialist I

About the Role

• Navigates various software applications and the electronic health record (EHR) to ensure accurate and timely completion of medical record documentation.
• Indexes medical records promptly for availability within the EHR to support patient care, the revenue cycle, regulatory requirements, and interoperability.
• Promotes a single-patient medical record strategy across all care settings.

Key Responsibilities

• Accurately upload/index outside records using applicable software, routing documentation to the clinician as appropriate.
• Create or select the appropriate patient, encounter, and/or order while assigning the correct document type and description when indexing into the EHR.
• Incorporate internal and external clinical documentation from various electronic and paper sources via applicable software work queues, rounding, eDelivery or importing into the EHR according to HIM procedures, while meeting established benchmarks for quality, accuracy, and productivity.
• Apply knowledge of medical terminology and nomenclature to accurately identify documentation needs based on patient service areas and level of service provided.
• Analyze the content of the medical record for missing documentation and signatures and assign/edit medical record deficiencies by the responsible provider into the chart management system according to State and Federal regulations, such as Det Norski Veritas (DNV) or The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), all Medical Staff Bylaws and organizational policies.
• Provide support and education to clinicians regarding record completion activities.
• Collaborate with Data Integrity or other functional areas to ensure errors in documentation discovered are communicated for Chart Correction.
• Notify appropriate leadership for quality review and privacy investigation.
• Ensure clarity, legibility, and position of scanned documents are readable by the end-user or indicate best quality.
• Serve as a point of contact for record completion support for clinicians and other providers.

Requirements & Tech Stack

• Proficient computer and keyboarding skills with the ability to learn new computer software systems such as Epic, OnBase, Solarity, Microsoft Office, and legacy archives.
• Familiarity with electronic communication and meeting platforms such as Teams.
• High attention to detail and accuracy with frequent interruptions.
• Ability to prioritize workload and work under pressure in a fast-paced environment with time constraints.
• Ability to work independently and make decisions with minimal supervision while maintaining quality and productivity standards.
• Ability to work collaboratively in a diverse team environment with openness and respect to learn, create and problem-solve.
• Ability to adapt to a fast-paced environment and transition to switching tasks without issue while maintaining quality and accuracy.
• Ability to learn when receiving constructive feedback by leadership or peers and taking personal ownership for success.
• Strong interpersonal and communication skills.
• Ability to safeguard protected health information (PHI) and basic knowledge of HIPAA.

Qualifications

• High School Graduate or Equivalent
• Licensure, Registration, And/Or Certification: None Required

Work Environment

• Operates all equipment necessary to perform the job.
• Exposed to a normal office environment.
• Sits most of the workday.
• Ability to perform repetitive functions and hand movements in a normal office environment.