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Job Summary:

The HIM Specialist provides timely processing of the patient records. The HIM Specialist will be responsible for completing the prepping, scanning and indexing of patients' medical records into our Electronic Health Record (EHR), to include all hospitals departments and WellStar Medical Group practices. In addition, the HIM Specialist will be responsible for monitoring, and the management of HIM work queues, reviewing documents and the creation of indexes, abstracting, completion and submission of vital records information, and other duties associated with the accurate and timely completion of the legal medical record.
The HIM Specialist is responsible for reviewing documents and creating indexes. This allows the end user to locate documents quickly and easily for continuity of patient care, coding, billing, release of information, compliance and regulatory standards. This job requires strong problem-solving skills, decision making, research, analytical ability, and great attention to detail. The HIM Specialist must acquire and maintain comprehensive knowledge of the document types required to associate patient documents in the EHR to facilitate end user access and selection. This job requires extensive knowledge and proficiency of the EHR to designate the documents to the correct patient, encounter level, document type, physician and location.

Core Responsibilities and Essential Functions:

Ambulatory and Inpatient Indexing
* Verifies scanned documents for quality and poor-quality images. Routes for rescan as needed.
* Electronically tags a document with poor quality images to identify poor quality originals.
* Evaluates to determine if there is a discrepancy with the document (i.e. incomplete form, new forms, missing patient identification, wrong patient label on form, two patients on one form, etc.) that requires routing for additional review and resolution.
* Verifies that the origin of the WellStar Medical Group capture profile is assigned to the correct location. Reports discrepancies to the Supervisor of Document Management.
* Defines whether the scan is a patient, encounter or order level document by reviewing the document type list. The level of the document will determine if the patient information is available across the continuum of care or only to a specific time period. The form is analyzed to determine the correct document type, so it is appropriately classified for continuity of patient care and to allow the end user to locate documents quickly.
* Ensures document types are consistently named the same as defined by departmental procedure.
* Identifies the correct patient identification by reviewing every document for two patient identifiers. Electronically tag a document with a second identifier if it is missing on all forms. Electronically tag a document if pages are missing in a multiple page document.
* Chooses the correct encounter date by comparing the date of the documents against the dates in the EHR. The document must be in the correct encounter for accuracy of patient data, billing and compliance.
* Creates an encounter in the EHR for ambulatory indexing if the encounter status is not active or greater than 60 days. Selects the appropriate location and physician from the WellStar Medical Group practice listed in the EHR.
* Ensures the documents are assigned to the correct hospital location, WellStar Medical Group Practice or outpatient department. This requires attention to detail to verify where the document will be placed in the EHR.
* Identifies when the next patient appears in the batch and separates the documents appropriately.
* Performs document imaging in accordance with policy and departmental quality control standards.

Document Management
* Retrieves and reconciles records of discharged patients from all hospital units (including inpatient, outpatient surgery, procedural areas, emergency department, etc.)
* Prepares the documents according to departmental procedure so it is available for scanning.
* Scans the documents into the document management system according to departmental procedure so it is available for indexing.
* Assist with management of document and EMR work queues related to the timely and accurate completion of the legal medical record.

Vital Records Data Abstraction and Record Completion
* Reviews the birth registration worksheets completed by the mother or father to determine the completeness and accuracy of the information
* Conduct patient interviews to complete the paternity affidavits as applicable
* Telephones parents/and or contacts physicians to obtain any missing data not collected during the admission.
* Provides a birth verification (confirmation letter of birth) and social security letter to parents for their records and use in providing information to health/governmental agencies, and insurance companies
* Reviews the Death Certificate work queue in Epic and certifies death certificates on behalf of the physician when the proper documentation is present.

Performs other duties as assigned

Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• High School Diploma General or Associates Health Information Management-Preferred or Bachelors Other-Preferred

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 2 years more years of experience in an acute care hospital with experience with HIM document management system. Required and
Computer/data entry experience. Required and
Epic and OnBase experience Preferred

Required Minimum Skills:

Ability to communicate with various members of the healthcare team.
Ability to use EXCEL, Word and have basic computer operational knowledge.

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