Reviews medical records for completeness in compliance with the hospital’s bylaws, HFAP standards, federal and state requirements. Provides data support by performing medical record reviews and data entry, creating and maintaining spreadsheets, databases and data collection forms, compiling results into report and graphical presentations and performing data verification, validation and reporting to the required external reporting agencies.
Files required information into proper medical record.
Assembles patient medical records to release upon consent of patient or as allowed for treatment, payment and healthcare operations, and releases records according to policy.
Immediately notifies HIM Manager if records have been disclosed inappropriately
Retrieves old records from previous EHR and scans or sends to requestor
Analyzes medical records for completeness and accuracy according to department and hospital policy and procedures
Enters deficiencies into computer and keeps a current log of those deficiencies
Performs audits as part of performance improvement on medical records when directed by the HIM Manager
Assists in answering telephone and taking accurate messages
Maintains hospital requirements, policies and standards on confidentiality
Assists in retrieving medical records for physician completion and obtains signature if needed
Possibility of on-call hours
Responsible for completing all birth certificates and death certificates, which includes entering the data into the state website.
Willing to accept additional assignments
Must be able to keep up with workload. Be able to process a minimum of 20 medical records per day
Training of other software interfaces for maintaining a complete medical record
Maintains a good working relationship within the department and other departments
Must comply with OSHA standards and universal precautions.
Job Requirements:
Prefer associates degree in Health Information Administration or Technician, licensed nursing training or equivalent health care program
Preferred: Two or more years of previous similar hospital or clinic experience
Preferred: Knowledge of HFAP standards and state medical record requirements
Preferred: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) preferred
Prefer familiarity with medical record requirements of Nebraska and CMS.
Equal opportunity All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, protected veteran status, or disability status. Bryan Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee’s Form I-9 to confirm work authorization.
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