Department/Unit:

Work Shift:

Salary Range:

Essential Duties and Responsibilities

• Assist the HIM Operations Manager to ensure all clinical documentation is available to coding/billing and clinical staff via the electronic health record within 24 hours of discharge.
• Retrieves and sorts clinical documentation from departments when directed by the HIM leadership team.
• Prepares clinical documentation to be scanned by reconciling encounters, orders, referrals, etc. Follows up on incomplete records per departmental reconciliation guidelines.
• Prep, scan and index incoming clinical documentation from internal providers and external referrers in accordance with departmental policies and procedures.
• Performs a thorough review of all incoming documents via mail, faz, email, etc. and redirects them to the appropriate departments accordingly.
• Identifies documents, which constitute the legal content of the patient's health record, in both electronic and paper formats to ensure integrity of record.
• Assigns appropriate document types and supporting identifiers such as date of service.
• Assists in the collection and reporting of quality metrics related to PCMH and CMS quality measures by adhering to departmental policies that target appropriate mapping of the medical record (patient, encounter, or order level).
• Identify contents of incoming paper and electronic clinical documentation to appropriately reroute documents to physician, nurse, referral team or other department in accordance with department policies and procedures.
• Properly completes destruction of records once prep, scan, index, and QA processing has been fulfilled. Understands departmental record retention schedule and assists with tasks related to storing, retention, and purging patient records.
• Meets productivity and quality benchmarks and scorecard expectations set by the HIM Operations Manager.
• Collaborate with the team to enhance data accuracy and integrity of medical records.
• Notify HIM leadership of any workflow or build issues to mitigate potential problems as soon as possible.
• Performs other tasks and projects assigned by the HIM leadership team.
• Takes proactive steps to recognize active or potential security risks and report them to qualified IT staff or supervisor.
• Adaps to the diversity of the customer to understand complex issues.

Qualifications

• High School Diploma/G.E.D. - required
• . Will consider an associates degree in HIM with a minimum of 80 hours of practical experience in HIM in a hospital setting in lieu of work experience. - required
• Familiarity with EHR systems, ideally EPIC and OnBase.
• Basic understanding of Patient-Centered Medical Home (PCMH) and Centers for Medicare and Medicaid Services (CMS) quality measures.
• Ability to organize and establish day-today priorities
• Ability to multitask while remaining professional, focused, compused, and positive
• Excellent customer service skills
• Displays Integrity, friendliness and compassion
• Must be able to establish an appropriate and effective rapport with patients, coworkers, and medical staff
• Must be able to demonstrate effective and appropriate written and oral communication skills
• Ability to take and follow direction in a positive and appropriate manner
• Must be flexible
• Takes initiative/able to work independently
• Embraces new opportunities to grow both personally and organizationally
• Must be efficient and effective in the use of resources
• Basic computer skills such as but not limited to Excel, Work, and Microsoft Teams
• Ability to read and understand the English language
• Ability to effectively maintain confidentiality of records and communicate with all levels of personnel
• RHIA, RHIT - preferred

Equivalent combination of relevant education and experience may be substituted as appropriate.

Physical Demands

• Standing - Occasionally
• Walking - Occasionally
• Sitting - Constantly
• Lifting - Rarely
• Carrying - Rarely
• Pushing - Rarely
• Pulling - Rarely
• Climbing - Rarely
• Balancing - Rarely
• Stooping - Rarely
• Kneeling - Rarely
• Crouching - Rarely
• Crawling - Rarely
• Reaching - Rarely
• Handling - Occasionally
• Grasping - Occasionally
• Feeling - Rarely
• Talking - Constantly
• Hearing - Constantly
• Repetitive Motions - Frequently
• Eye/Hand/Foot Coordination - Frequently

Working Conditions

• Extreme cold - Rarely
• Extreme heat - Rarely
• Humidity - Rarely
• Wet - Rarely
• Noise - Occasionally
• Hazards - Rarely
• Temperature Change - Rarely
• Atmospheric Conditions - Rarely
• Vibration - Rarely

Thank you for your interest in Albany Medical Center!

Albany Medical Center is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:
Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

Thank you for your interest in Albany Med Health System!​

Albany Med Health System is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:

Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.