This hospital is designed as a bridge in the continuum of care and is intended to provide intensive, specialized care for medically complex patients that require a longer treatment and recovery period. This hospital provides a committed and knowledgeable clinical team in a setting conducive to healing. Their goal is to treat the immediate and long-term needs of the patients with the goal of helping each patient reach the next level of well-being on their path to a full recovery.

 Job Summary

Maintains health information management (HIM) integrity through knowledge of medical record content, medical terminology and abbreviations, abstracting and analysis techniques, concurrent medical record review, terminal-digit filing, medical record storage and retrieval.  Demonstrates knowledge of the legal aspects of patient medical records, including release of information and HIPAA Privacy and Security requirements.

Essential Functions

• Demonstrates ability to assemble, analyze, abstract, scan, and maintain medical records appropriately to ensure verifiable documentation.
• Responsible for working with hospital staff, physicians, and administration to ensure that medical records are completed timely, accurately, and completely in a manner that is consistent with hospital policy as well as medical staff bylaws/rules and regulations.
• Responds per HIPAA guidelines to inquiries and requests from physicians, staff, and outside agencies and/or individuals regarding protected health information.
• Demonstrates proficiency with dictation and transcription systems.
• Maintains record indexes and storage and retrieval systems.
• Orders supplies as needed by the department in adequate time to ensure that proper amounts are on hand at all times and that meet budget requirements.
• Demonstrates excellent oral and written communication and interpersonal skills. 
• Completes annual health, safety, and education requirements.  Maintains professional growth and development.
• Maintains confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected.
• Attends all mandatory in-services and staff meetings.
• Represents the organization in a positive and professional manner.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department.
• Maintains current licensure/certification for position, if applicable.
• Consistently demonstrates Guest Relation’s skills to patients, physicians, visitors, employees, and any other individuals with whom they may come in contact.
• Consistently follows departmental and hospital Health, Safety, Security, Hazardous Materials policies and procedures.

 Knowledge/Skills/Abilities

• Ability to investigate and analyze information and to draw conclusions.
• Must read, write and speak fluent English. 
• Medical data abstracting skills.
• Ability to foster a cooperative work environment.
• Must have good and regular attendance.
• Approximate percent of time required to travel: 0%25
• Performs other related duties as assigned.

Education

• High School Diploma or GED required.
• Associate degree in health information technology preferred, or enrollment in a college/university HIM program accepted. 

Licenses/Certification

• Certification as a Registered Health Information Technician (RHIT) by the American Health Information Management Association (AHIMA) preferred. 

Experience

• Minimum of 1 year of HIM experience preferred.