Health Information Technician (Inpatient)

Job Summary

Responsible for applying appropriate diagnostic and procedural codes for data retrieval and proper reimbursement, responsible for release of protected health information according to confidentiality laws, performs medical record scanning and filing, provides medical record support for Court proceedings, and keeps current with medical record best practices and law to assist in various medical record processes.

Essential Duties

Assigns diagnostic and procedural codes according to current classification system, to include acute care settings and long-term care settings. Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.

Releases protected health information from medical records in a timely manner when proper authorization for release of information is received or without client authorization when statutory exceptions apply.

Handles requests for medical records from Quality Review Agencies.

Responds appropriately to requests for protected health information that do not have proper authorization.

Requests client information from other facilities when necessary with proper authorization for release of information and routes reports when received.

Documents all release of client information according to established standards.

Scans medical records into electronic health record following correct indexing.

Completes insurance forms when appropriate authorizations for release of information have been completed and submits records when requested for retro-authorizations.

Reviews medical records to ensure completeness before indexing and filing.

Routes client reports from other facilities to appropriate staff.

Prepares certified copy of medical records for court hearings and copies appropriate information.

Maintains the confidential nature of client and business information.

Completes appropriate in-services and continuing education.

Completes and maintains necessary documentation according to applicable requirements and policies.

MATERIALS AND EQUIPMENT USED:

General office equipment

Computer

Minimum Qualifications Required

Education and Experience:

Graduate of Health Information Technician course; have one of the following: RHIA, RHIT, CCS, CCS-P, CPC certification; medical record experience, with emphasis on Coding and Release of Information; strong background in medical terminology, and computer data entry helpful; or any equivalent combination of education, training and experience which provides the necessary knowledge, skills and abilities.

Licenses and Certifications:

Registered Health Information Administrator (RHIA) certification; or

Registered Health Information Technician (RHIT) certification; or

Coding Certification, such as CCS, CCS-P, CPC.

Knowledge, Skills & Abilities

Knowledge of medical terminology, policies, procedures, regulations and laws governing the Medical Record Department.

Knowledge of and ability to utilize a computer and the required software.

Ability to answer inquiries and complaints effectively with tact and courtesy.

Ability to perform full data entry functions.

Ability to communicate effectively both orally and in writing.

Ability to establish and maintain effective working relationships with staff and the public.

Ability to operate standard office equipment.

Ability to work the required hours of the position.

PHYSICAL DEMANDS:

Lifting 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds.

Extended periods of sitting; intermittent standing and walking.

Using hand(s)/feet for repetitive single grasping, fine manipulation, pushing and pulling, and operating controls.

Occasional bending, twisting, squatting, climbing, and reaching.

Communicating orally in a clear manner.

Distinguishing sounds at various frequencies and volumes.

Distinguishing people or objects at varied distances under a variety of light conditions.