Health Information Tech

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It is the responsibility of a Health Information Technician to update and maintain patient health records in a manner consistent with compliance and processing medical records requests from various sources. The technician ensures that the information maintained meets quality, accuracy, accessibility, and security in paper files and electronic systems, and verifies that correct releases are obtained with federal and state regulations to release medical records, following all HIPAA guidelines.

• Retrieves discharge records from the appropriate units on a daily basis.
• Analyzes records for completion, dictation, orders, signatures, and charting to ensure complete documentation and compliance with guidelines.
• Verifies that all miscellaneous reports are filed in the medical record and that every document is accurate with the correct patient information.
• Manages patient identity by ensuring merges are handled in the EMR, identifying and merging duplicate medical records and charts.
• Maintains a sign‑out system for records that are incomplete or need to be signed out.
• Assists in pulling charts for audits, requests from other departments, or providers.
• Files medical records and retrieves files from areas when needed.
• Follows all organizational and department policies.
• Sorts and opens mail, reviews incoming mail and correspondence.
• Answers phone in the department and provides professional customer service in phone, personal, or electronic communication.
• Reviews correspondence and forwards it to other departments if needed.
• Completes work assignments on time and works well as a team player.
• Coordinates the release of medical records to insurance companies, lawyers, state and federal agencies, patients, and other providers within established policies and guidelines.
• Maintains confidentiality of all hospital and patient information at all times and follows HIPAA regulations and policies.
• Communicates with patients, physicians, families, and co‑workers in person and by telephone.
• Ensures regular and predictable attendance, an essential job function.
• Ensures Patient Rights are followed as outlined in HIPAA;
  Patient Right to Amend the medical record, Patient Right to Restrict the medical records, and Patient Right to view the medical record.
• Processes birth certificates and files paternity affidavits in accordance with state and hospital guidelines.
• Manages missing documentation work lists or work queues.
• Assists physicians and providers in chart completion or reanalysis by clarifying deficiencies or explaining the chart completion process in the electronic or paper record.
• Assigns documentation deficiencies to the correct clinical staff.
• Performs medical record audits, identifying patterns and trends as needed.

• High School diploma or equivalent.
• Knowledge of HIPAA preferred.
• Experience with medical records within a healthcare setting preferred.