Health Information Technician III FT Days

DMC Sinai-Grace Hospital is DMC's largest hospital, offering a comprehensive heart center, cancer care, gerontology, emergency medicine, obstetrics/gynecology and cosmetic services. Sinai-Grace's joint replacement program features a revolutionary minimally invasive knee and hip replacement surgery that attracts patients from all over the country. Sinai-Grace operates more than 21 outpatient care sites and ambulatory surgery centers throughout Wayne and Oakland Counties and is one of 10 hospitals in the nation to be awarded a Robert Wood Johnson Foundation grant to help set the standards of cardiac care for hospitals and physicians throughout the nation.

Summary Description

• Reconciles records against discharge census and takes appropriate and timely action to retrieve all discharged patient records

• Retrieves medical records from designated Patient Care areas, organizes, prepares and processes for document imaging

• Meets departmental quality and productivity standards for preparing, and scanning of patient records

• Other job duties as assigned based on skill level and need

o Movement of medical record documentation from incorrect to correct account numbers
o Paper to Image audits for scanned records

Performs birth and/or death records processing including, but not limited to, the following:

Birth Process:

• Processes birth certificates and affidavits of parentage
• Prepares and submits completed birth certificates to the Department of Health biweekly
• Assists walk-in customers in obtaining information concerning birth certificates and establishing paternity. Assists the state in updating records, providing information as to where the deceased infants were released.

Death Process:

• Ensures completion of Expiration documentation in medical record
• Ensures completion of Death Certificate
• Follow-up with physicians, Social Work, Security and Funeral Homes as needed
• Completes Morgue and Death Certificate Logs
• Works with Funeral Homes on body release
• Ensures all paper death-related forms are sent for scanning into the medical record

• In accordance with CMS and Joint Commission requirements, Medical Staff Policy and DMC Medical Rules and Regulations, performs the following functions related to medical record analysis and chart deficiency assignment/resolution:

o Analysis of in house patient medical records to determine if required History & Physicals and Operative Reports, as applicable, are complete, present and accounted for, with completed attestations and co-signatures as required

o Analysis of discharged patient medical records to determine if all required components are complete, present and accounted for, with completed attestations and co-signatures as required

o Accurate and timely assignment of deficiencies in Cerner Profile as appropriate

o Update status of accounts in 3M HDM, consistent with Profile deficiencies

o Contact physicians regarding delinquent records/missing documents

• May assist physicians with document completion process/access issues if needed

• Identifies and issues/patterns related to specific physicians, document types, etc., and escalates to leadership as appropriate

• Assists Supervision and Management with compilation of accurate and timely chart delinquency and suspension lists

• Must meet department productivity standards for chart analysis

• Assist with other job functions/projects as assigned by management; This may include but is not limited to the following:

o Assistance with Prep/Scanning Activities
o Movement of medical record documentation from incorrect FIN/Patient to correct FIN/Patient
o Paper to Image Audits for scanned records
o Periodic medical record reviews for Joint Commission and CMS requirements

Qualifications:

Minimum Qualifications

• High school diploma or GED required; AAS in Health Information Technology preferred.
• Two years of experience working in a Medical Records department or the equivalent experience completing medical records duties in another setting, or the completion of at least 30 credit hours of a Health Information Management Associate's degree program preferred.
• Basic Windows-based computer experience required; Excel and Word experience necessary.
• Understanding of HIPAA Privacy Rules.

Skills Required

Minimally:
• Analytical skills
• Organization and time management
• Windows-based computer experience, especially Excel and Word

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