Job Summary: Under general supervision of the HIS manager, the lead will be a contact point for HIS and clinical staff and work together with the department manager on day to day operations/coverage as needed. The lead medical records associate will assist with leadership, communication, and training. Responsible to rotate through HIS duties, monitor daily completion of tasks, re-assess/re-distribute workload as needed, and work cooperatively with all HIS staff, physicians, internal and external customers. Practices and coaches the team concept approach, prepares action plans, and shares common outcomes with HIS staff. Develops data reporting tools and coaches team members to proficiently utilize the tools in performing their daily responsibilities. The lead medical records associate will monitor quality and quantity of work and ensure adherence to applicable requirements and regulations.
Assist the manager in overseeing the day-to-day operation of the HIS Dept. Complete the weekly calendar assignment and update as needed to account for staff out of the office.
Ensure the daily scanning/indexing/correspondence duties are completed within the established time frames.
Assist with conducting audits of documentation management system and EMR for accuracy.
Assists with initial and ongoing departmental orientation and education to assigned staff.
Problem solve with other HIS staff and clinical staff any outstanding/incomplete documentation received in HIS.
Communicate with HIS manager on any outstanding or un-resolved issues.
Assist in training of new HIS staff when needed
Assist in EMR problem solving
Assist HIS staff with deescalating issues with internal or external customers
A thorough working knowledge of HIPAA Privacy Practices, 42 CFR Part 2, Release of information
A thorough working knowledge of HIS policies and procedures and can assist patients and staff relative to HIM Department responsibilities regarding authorizations, patient access, request for amendments, accounting of disclosures, and minimum necessary standards.
Monitor quality and quantity of work and ensure adherence to all applicable regulations
Ensure that work assignments of the team are carried out by successfully performing duties which include distributing and balancing workload, monitoring the status and progress of work, instructing and answering employee questions, checking employee work, and amending or rejecting work not meeting standards.
Participate in maintaining departmental continuous quality improvement.
Filling in for the HIS manager as needed
Compile and submit data reports to HIS manager as needed
Scribe for all HIS team meetings
Scanning and Indexing Duties:
Knowledge of the Docuware Electronic Medical Record process and Epic.
Ability to complete scanning, indexing and ready to file of any outstanding forms by the end of each business day.
Process “priority” scanning/indexing each hour as required (medication sheets, outside clinical paperwork, etc.)
Assist in indexing and processing any documents received in the HIS “incoming email”
in Docuware (by location).
Ensure client numbers match client names; audit and problem-solve any errors or potential problems.
Complete scanning of the medical records after verifying all documents are completed in entirety as per facility policy and procedure.
Aware and approve of all tickets placed with IS for Docuware, scanning or other technical issues.
Admissions & Discharge process: ensure that all paperwork is processed in order to open/discharge clients. (Refer to EMR when necessary).
Conduct audits of Docuware for accuracy of scanning, dates, etc.
Perform look-up of client names and identification numbers within both AS400, Docuware, Client Search, and EPIC.
Process releases of information; pull any old records along with look up information in EMR, in order to provide accurate copies of medical records as requested.
Process releases within 5-7 business days and mail and/or fax information as required.
Document/log releases as required.
Understand HIPAA regulations around faxing emergency information under the coordination of care laws.
Prepare record requests for subpoenas, depositions and court orders.
Communicate with attorneys and courts to ensure copies of records are prepared in accordance with laws and regulations.
Attend court if necessary.
Track and data enter all releases and subpoenas that are processed. Process Social Security Income requests. Contact SSI for eligibility dates and copy records (both hard copy and Docuware/Epic) as required.
Customer Service Duties:
Maintain cooperative relationships with other employees, consumers and the public.
Demonstrate a caring and helpful attitude when interacting with clients and fellow coworkers.
Effectively communicate with HIS staff, Clinical staff, and various local agencies.
Deal with co-workers regarding problems in a constructive manner.
Accept and use direction and supervision.
Benefit from constructive feedback.
Ability to deal tactfully and professionally with employees and clients under periods of stress.
Ensure no complaints received by peers, supervisor and the public.
Answer and respond to incoming phone calls and emails in a timely and efficient manner. (Standard is to answer phone within 3 rings and identify yourself at each phone call).
Respond to questions pertaining to Health Information Services and investigate if answer is not known until resolution.
Attend trainings and conferences/attend center meetings as required.
Complete mandatory trainings as required by The Center.
Provide coverage in other HIS areas as necessary.
Complete any other duties if assigned by HIS Manager and/or Director and Associate director of Compliance and Quality Improvement.
High school diploma or general education degree (GED) required. One to three years of medical records experience required.
Must possess the ability to communicate effectively, gain credibility and develop productive relationships with management, staff members and other customers.
Must have strong decision making skills and ability to work independently.
Must possess excellent written and oral communication skills in addition to excellent problem solving, interpersonal, and organizational skills.
The ability to demonstrate experience in leadership skills, proven abilities to set priorities and multi-task. Team oriented individual who shows initiative and demonstrates flexibility.
Ability to maintain composure when faced with difficult situations.
Skilled in organizing large quantities of documents, working quickly and accurately.
Must possess excellent spelling skills, strong attention to detail, strong problem solving skills and critical thinking, strong technical skills using the facility’s EMR system and Microsoft Office products. Proven abilities to set priorities and multi-task.