Health Information Technician I

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

Essential job functions:

• Retrieve discharge records from the appropriate units on a daily basis.
• Analyze records for completion, dictation, orders, signatures, and charting to ensure complete documentation and compliance with guidelines.
• Verify that miscellaneous reports are filed in the medical record and that every document is accurate for the correct patient.
• Manage patient identity in the EMR by identifying and merging duplicate medical records and charts.
• Maintain a sign-out system for records that are incomplete or need to be signed out.
• Assist in pulling charts for audits and requests from other departments or providers.
• File and retrieve medical records as needed.
• Sort and open mail, review incoming correspondence, and forward items to the appropriate departments when needed.
• Answer department phone calls and provide professional customer service in person, by phone, and through electronic communication.
• Coordinate the release of medical records to insurance companies, attorneys, state and federal agencies, patients, and other providers according to policy and guidelines.
• Maintain confidentiality of all hospital and patient information at all times.
• Communicate with patients, physicians, families, and co-workers in person and by telephone.
• Ensure patient rights are followed under HIPAA, including the right to amend, restrict, and view medical records.
• Process birth certificates and paternity affidavits according to state and hospital guidelines.
• Manage missing documentation work lists and work queues.
• Assist physicians and providers in chart completion or reanalysis by clarifying deficiencies and explaining the chart completion process.
• Assign documentation deficiencies to the correct clinical staff.
• Perform medical record audits and identify patterns and trends as needed.