Community Health and Rehabilitation Center
The Health Information Technician/Practitioner organizes, manages, evaluates, and continuously improves the Health Information Management Department and systems according to established professional practice standards and center policies and procedures.
DUTIES: These are all the duties of the HIM Department. If there is more than one employee in the department, these duties will be divided for appropriate work-load, however, all members of the department will be cross-trained for all duties.
Health Information Management Practices:
- Perform all assigned duties related to the admission and discharge of patients to properly identify and monitor the location of, the patient and the patient’s health information, including:
- Researching and assigning unit medical record numbers
- Making, placing, and updating armbands, doortags, chart tags, and patient identification photos (each, as assigned)
- Assembling new chart materials;
- Retrieving discharge charts and forms, as needed.
- Audit admission/transfer documentation and obtain missing reports, as needed.
- Maintain accurate records of admissions, transfers, returns and discharges in paper and/or electronic formats.
- Research, sequence, and code (using ICD-10-CM) all current and relevant diagnoses, update codes as needed, and record diagnosis codes in the patients’ records and appropriate indices.
- Establish, maintain, and store paper and electronic health information in organized and accessible formats and locations for efficient use by care givers and other authorized persons. Maintain sign-out and follow-up controls for record location.
- Audit all medical records at established, regularly scheduled intervals to monitor completeness, accuracy, and internal consistency.
- Communicate with and assist all care givers (including physicians, nurses.
- therapists, and other allied health professionals) in establishing, maintaining, and updating the records.
- Maintain the timely flow of reports and signed materials to the medical records. Identify and label reports as needed.
- Periodically thin older reports and file them in the overflow file to maintain the volume of active medical records at an appropriate level.
- Provide health information as needed for center committees, statistical reports, and as instructed by the administrator.
- Maintain and control the release of health information to authorized persons.
- Any other related duties as assigned by the administration.B. Health Information Department Duties:
- Supervise employees within the Health Information Department, include:
- Interviewing, hiring, evaluating, disciplining, and terminating employees, as needed.
- Organizing and delegating tasks; providing orientation and inservice training as needed.
- Orient new center employees and provide inservice training concerning health information practices for all employees.
- Attend center and other meetings as required by the administrator.
- Develop, ,monitor, and ,maintain compliance with the HIM Department budget.
- Keep the HIM Department neat and orderly for a professional appearance. Monitor and order supplies as needed.
- Other related duties as assigned by the administrator.
- Credentialed Health Information Department Directors may serve as preceptors to local students in HIM/HIT programs.
- Serve as Quality Assessment and Improvement Coordinator, as assigned.
- Organize and maintain the Medicare Certification process and the Utilization Review meeting minutes, as assigned.
- Good verbal and written communication skills. Ability to type and use a computer required. Working knowledge of medical terminology, ICD 10 CM coding, and basic medical-legal practices preferred, but not required.
- Ability to organize time and work independently with very little supervision.
- Experience in supervision a plus. Ability to establish procedures and to suggest changes for smoother operations.
- Physical Demands:
- Ability to read, write, hear and communicate adequately to complete job duties and responsibilities.
- Ability to move throughout the center without assistance.
- Must be able to see adequately enough to read hand-written medical records.
- Ability to lift medical records up to ten pounds at a time.
One year of Health Information Management experience preferred, but not required.
- Certification as a Registered Health Infonnation Administrator (RHIA]RRA) or as an Registered Health Information Technician (RHIT/ART) preferred, but not required.
- If credentialed, active member of the American Health Information Management Association with Continuing Education current.
- High school graduate or equivalent required. Associate degree preferred.
Based on qualifications and experience.
Instructions for Resume Submission:
Please submit resume to MMartin@BallHealth.com or fax resume to 850-747-9992.