Overview Health Information Management Specialist (HIMS) uses office automation systems and various software packages to accomplish assignments (include: medical records audits; release of information tasks; document and order denial management; patient registrations; transcriptions; patient communications). Reviews own health information management work for accuracy and quantity and maintains all pertinent records. Pay: $21.99/hr + 4.41/hr HW Schedule: Works Monday through Friday. Shifts may be 8 to 10 hours per day, but will not go over 40 hours a week. Duties will need to be performed at the MFT during core hours (0700-1700). Responsibilities Performs the full spectrum of services of a HIM Specialist. Provides accurate support of digital and physical workflows in the following tasks: medical records audits, medical records file builds, release of information, document and order denial management, patient registrations, transcriptions, and patient communications. Provides accurate medical transcription service in accordance with standards set in the Medical Transcription Industry Alliance and in compliance with all security requirements for safeguarding patient information and prevention of Privacy Act violations. The HIM Specialist shall provide transcription of dictation on an ad hoc basis and ensure completed transcription is medically consistent and accurate in content. The HIM Specialist shall review dictation for accuracy and meaning to ensure that dictated test results are consistent with associated patient symptoms or diagnoses. The HIM Specialist shall call the originator of the dictation regarding clarification of dictation or questions regarding specific issues. The Specialist shall obtain complete patient data that may involve researching the patient information or contacting the originator. The HIM Specialist shall review, code, and analyze medical records to identify inaccurate entries and/or omissions. They shall plan, organize, and accomplish the review, analysis, and coding of medical records utilizing a variety of means to identify coding requirements. The specialist analyzes patient records that may include multiple injuries, diseases, and/or medical/surgical procedures, determining both accuracy and completeness. They shall determine if/when deviations from proper terminology may indicate omission or inaccuracy within the record and initiate actions to obtain clarification, coordinating work-up of medical charts with staff physician. The HIM Specialist shall examine records and ensure documentation requirements are met. The Specialist shall be responsible for entering record processing data into computer systems for record completion and assisting physicians in the completion of deficiencies. The HIM Specialist shall perform releases of medical information. Upon receipt of written requests, the Specialist shall follow standard operating procedures to research, analyze, and abstract pertinent information from records that may include multiple injuries, diseases, and/or medical/surgical procedures and report findings to requestors. The HIM Specialist shall make release determinations based upon application of the Privacy Act and other directives covering confidentiality. The Specialist shall verify validity and entitlement to access of information prior to release. They shall send questionable requests to the legal office for review/recommendations. The HIM Specialist shall brief patients and agencies such as insurance companies, social services, and medical activities on policies associated with releasing medical information. The HIM Specialist shall ensure proper billing procedures are initiated upon completion/fill of request. The Specialist shall initiate, post charges, and forward billing statements to appropriate accounting officer for action. The HIM Specialist maintains an accurate and detailed record of all requests to ensure proper tracking and reporting. The Specialist shall scan the written authorization and medical record and make copies of records either on paper or electronic media in accordance with federal, state, and HIPAA/Privacy regulations. HIM Specialists shall treat patient lists as privileged information. Lists and/or names of patients shall not be disclosed to or revealed in any way for any use outside the MTF without prior written permission by the SGH, 10th Medical Group. HIM Specialists performing transcription work shall release medical information obtained during the course of this contract only to other MTF staff involved in the care and treatment of that individual. HIM Specialists shall perform registrations of patients using the DoD Electronic Health Record. The Specialist will communicate with staff and patients directly to accurately transcribe personally identifiable information for the build of a new patient record. They shall follow prescribed workflows to complete patient registrations and validate accuracy of the patient record prior to completion. HIM Specialists shall perform order and denial management tasks using the HIM refusal inbox and standard workflows for the DoD Electronic Health Record. The Specialists shall forward refusals and denials from the HIM refusal inbox to the most appropriate or corrected provider. HIM Specialists shall maintain open and professional communication with members of the MTF. HIM Specialists shall complete the applicable reports/forms by following the instructions on the forms or provided by the MTF. Meets short-notice suspense as established by the organization. Be productive and perform with minimal supervisory direction. Ensure a safe work environment and employee safe work habits. Maintains a professional manner and displays a positive cooperative attitude. Procedure Guidance: Contractor personnel shall perform procedures compatible with the Medical facility's operating capacity and equipment. New medical procedures/services shall not be introduced without prior recommendation to, and approval of, the MTF Commander or authorized representative. Patient Sensitivity: The Contractor personnel shall provide patients with the utmost care and attention. All patients shall be assured of their privacy and personal dignity. The Contractor personnel shall perform other duties as assigned in support of the department, flight, MDG, and base. Qualifications English Language Requirement and Citizenship: Must be able to read, understand, speak, and write English well enough to communicate effectively and must be a United States Citizen. Education: HIM Specialist must have a high school degree or GED equivalent. Experience: HIM Specialist must have a basic knowledge of computers with the ability to type 1,200 lines per day and shall, after an initial training period, have sufficient experience to be capable of performing his/her duties. Will use approved DOD medical information systems on a daily basis. The HIM Specialist will use government approved systems to transcribe dictations and compile medical records. Knowledge of patient medical records and knowledge of medical terminology to interpret provider intent are preferred.
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