Health Information Technician I in Lompoc, California at Lompoc Valley Medical Center

Salary Range: $18.75- $24.00

Pay rates are determined based on experience and internal equity.

Position Summary:

• The Health Information Technician is responsible for analysis of medical records of all discharged patients, assignment of physician deficiencies, and the scanning and validation of relevant paper portions of medical records, to ensure medical record compliance with all relevant laws and regulatory requirements.
• This position reports to the Health Information Management Dept. Lead.

District Responsibility:

• Support of the District Mission and Values
• Demonstrate Respect, Professionalism and Courtesy to all patients, visitors, other providers and coworkers, as delineated in the LVMC “Commitment to Care”.
• Constantly use C-I-CARE principles when communicating with others.
• Performance Improvement Activities
• Professional Development

Position Duties/Responsibility:

• Analyzes and updates electronic and paper portions of medical records to ensure compliance with rules and regulations of the Medical Staff and other regulatory requirements.
• Determines if medical record documentation for operative/procedure note, discharge summary, and/or history and physical have been completed, and meet LVMC medical staff bylaws, and LVMC Medical Record Guidelines for Physicians Policy and Procedure.
• Determines whether any documents or portions of documents (electronic or paper), including signature requirements, are missing or incomplete.
• Accurately and correctly assigns physician chart deficiencies in the hospital EHR system.
• Organizes and prepares paper documents for scanning into the electronic health record (EHR).
  • Ensures records have been assembled and processed to standard prior to scanning process (including scanning, indexing, quality checking, archiving).
  • Evaluates errors or questionable patient identification linkages by evaluating Master Patient Index history. Requires understanding of name researching processes for evaluating correct assignment of account and related documents assigned.
  • Prepares and inspects paper documentation to ensure quality scan images can be produced from the hard copies.
  • Validates each document assignment type and patient label for each record. Includes placing soiled or contaminated documents within protective plastic sleeves for continued handling.
  • Reviews document orientation, thumbnail image as documents are scanned into the system.
  • Assigns (via data entry) a document type to each scanned image and assures that each page belongs to the proper Patient Folder/Encounter.
  • Validates 100% of scanned paper records to ensure scanning into the EHR maintains record integrity in accordance with state and national documentation standards.
  • Understands and is able to demonstrate secondary processes of converting originals for ease of scanning and document integrity (copying, reprinting, validation with originating department/service area).
  • Follow-up on any exceptions to 100% accuracy of paper-to-electronic conversion to make sure each source document/medium is identical and belongs to one patient or one patient account.
  • Manage any document that fails to scan correctly or is corrupted by system server errors. Ensure any document failure is reprocessed and scan as a true representation of the paper record.
  • Demonstrates ability to correct and amend records within defined procedures.
  • Scans and manages any revisions to documentation from all providers of care documenting within the medical record. Appropriate guidelines should be followed to ensure timely, appropriate entry and time frame allocation to the imaged record.
• Understands HIM functions related to data integrity requirements and standards in both paper and electronic mediums.
• Has a working knowledge of all medical record forms and their point of origination for use throughout the entire hospital service area.
• Determines if documentation is in the correct account.
• Completes chart corrections as needed in the appropriate EHR system, or with the appropriate hospital or clinic department.
• Ability to research and determine if a duplicate medical record number exists. If found, the ability to follow the process for merging medical record numbers.
• Assists with phone calls, faxes, emails, and in-person requests for medical records and/or information for customers. This includes a basic understanding of Protected Health Information/HIPAA guidelines.
• Must be able to prioritize work to meet overall objectives of the HIM department.
• Demonstrate quality and effectiveness in work habits including attention to details at the record, patient, and document level.

• Must demonstrate position competencies, teamwork and service excellence.
• Provide support at other LVMC locations as needed to ensure adequate staffing and maintain efficient operations.
• Other Duties as Assigned by HIM Lead and/or Director.

Essential Functions:

• Personal computer skills to manage multiple systems and screens for performing work functions.
• Strong attention to detail to ensure the accuracy of data and information, and to detect any inconsistencies or anomalies in medical records.
• Technical ability to utilize electronic health record system and various scanning hardware and software and to understand impact links to the medical records.
• Understand and comply with the laws and regulations related to health information, including the Health Insurance Portability and Accountability Act (HIPAA).
• Ability to maintain confidentiality and adhere to ethical standards for the handling of sensitive patient information.
• Protect the security of medical records to ensure that confidentiality is maintained
• Must have excellent reading, writing, spelling and grammar skills.
• Must have excellent verbal communication skills.
• The ability to use the keyboard to do data entry.