HIM Tech II-Medical Records
CHRISTUS Santa Rosa
SRHC Shared Services-30600
2827 Babcock Road
San Antonio, TX 78229
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The HIM Tech II is responsible for efficiently and accurately prepping, scanning, indexing, and quality checking documents into the Horizon Patient Folder (HPF) document imaging system. Associate is able to prioritize duties, work with limited supervision, and able to troubleshoot all equipment and process. HIM Tech II is also responsible for assisting medical staff and other hospital personnel with medical record request. Prioritizes and codes medical records, using ICD9-CM and CPT codes. Abstracts data from medical files and keeps required statistics. Assists with quality assurance and utilization review functions.
EQUIPMENT/SKILLS:1. Knowledge of basic medical terminology. 2. Able to read difficult and semi-legible script. 3. Able to analyze/quality check patient charts to verify if medical records are missing dictated reports (History & Physical, Operative Reports, and Discharge Summaries), missing physician orders and signatures. 4. Demonstrates the ability to assign and clear deficiencies to a physician in HPF. 5. Ability to answer questions asked by medical staff regarding HPF chart completion. 6. Ensure timely processing of medical records; documents should be prepped, scanned, and indexed within 48 hours of discharge.
7. Directly supervises the discharge medical records processing activity. Reconciles all discharges daily with the appropriate department ensuring that all recordshave been received. Follows up daily until all records are provided to the HIM Department. 8. Utilizes appropriate computer systems within the department to be able to process the workflow daily. 9. Pull paper and electronic charts for physician review, audits, and research. 10. Register new born babies into appropriate clinical systems and submit data to the state. 11. Review dictated reports for accuracy, coordinate with medical staff on dictation errors, and assign new dictation numbers. 12. Reconcile charts after discharged and follow up on missing documents/records 13. Utilizes appropriate computer systems within the department to be able to process the workflow daily 14. Prepare daily productivity and provide to manager on a weekly basis. 15. Ability to train staff on daily functions. 16. Strong organizational skills and ability to multi-task.
- Credentials Required.
- Registered Health Information Management Administrator (RHIA) or Technician (RHIT) graduate of an approved college program for Health Information Management or graduate of the American Medical Record Association's Independent Study Course for Medical Record Technicians; or Certified Coding Specialist (CCS).
- If not certified must be eligible to take one of the above mentioned exams, and must obtain credentials/certifications within 12 months of hiring date.
- College courses in medical terminology and anatomy and physiology.
- Demonstrate competence by achieving an accuracy ratio of greater than 96% on hospital coding examination.
- Three (3) years previous acute hospital inpatient and outpatient coding experience required.
- Must possess a good background in medical terminology and anatomy and physiology as the fundamentals of medical science.
- Must be knowledgeable of the application of the International Classification of Diseases and Operations, Ninth Revision, Clinical Modification, (ICD-9-CM), and Current Procedural Terminology (CPT), Diagnosis Related Groups (DRG) and Ambulatory Payment Classifications (APC).
- Must be familiar with physicians' handwriting.
- Must be familiar with the content and arrangement of the medical record.
- Must be familiar with other functions in Medical Records and how they relate to the Coding function.
- Registered Health Information Management Technician (RHIT).
- Registered Health Information Management Administrator (RHIA).
- Certified Coding Specialist (CCS).