The HIM Specialist is responsible for the accurate maintenance, organization, protection, and processing of patient health information. This position ensures that medical records are complete, accurate, accessible, secure, and confidential while maintaining compliance with applicable healthcare regulations, organizational policies, and industry standards.

The HIM Specialist also transcribes and interprets dictated documentation from physicians and other healthcare providers to accurately capture patient care information. This role requires a strong understanding of medical terminology, clinical documentation, and healthcare processes to ensure the integrity, accuracy, and quality of the medical record.

In addition, the HIM Specialist researches documentation-related questions, investigates discrepancies, and works collaboratively with providers and staff to obtain necessary clarifications and ensure documentation completeness.

Essential Duties and Responsibilities:

• Produces medical reports, correspondence, records, patient-care information, statistics, medical research, and administrative material.
• Performs data entry and data retrieval services, providing data for inclusion in medical records and for transmission to physicians.
• Returns dictated reports in printed or electronic form for physicians' review, signature, and corrections, and for inclusion in patients' medical records.
• Distinguishes between homonyms, and recognizes inconsistencies and mistakes in medical terms, referring to dictionaries, drug references, and other sources on anatomy, physiology, and medicine.
• Monitors the timeliness and completeness of physician documentation in accordance with established standards and distributes deficiency reports as needed.
• Responsible for extracting data for monthly and annual reporting and statistics, including but not limited to the service analysis.
• Maintains quality assurance standards of all scanning and indexing throughout the organization.
• Performs charging and data extraction activities to support appropriate levels-of-care determinations for surgeries, emergency department visits and observation stays.
• Identifies mistakes in reports and works with physicians to obtain the correct information.
• Assists patients, providers and authorized third parties with requests for the release of information (ROI) in accordance with application regulations and organizational policies.
• Participates in call time on weekends and holidays for medical transcription and other HIM records as needed
• Protects patient privacy and confidentiality in accordance with HIPAA and privacy laws.
• Ensures patient satisfaction, including troubleshooting when there is a complaint and developing process improvements to prevent reoccurrences.
• Demonstrates clear ownership of workplace and patient safety.
• Report mistakes, near misses, adverse events and quality and safety concerns.
• Participates in the development and implementation of safety and quality improvement activities.
• Other duties as may be assigned.

Job Requirements

Education: High School Diploma or GED required.

Certification/Licensure: Certified Healthcare Documentation Specialist (CHDS), Registered Health Information Technician (RHIT), or other related Health Information Management certification preferred.

Experience:

• Knowledge of medical terminology, anatomy, physiology, and clinical documentation practices.
• Knowledge of medical transcription guidelines, standards, and best practices.
• Proficiency in English grammar, spelling, punctuation, and writing style.
• Ability to utilize professional reference materials and healthcare documentation resources.
• Proficiency with word processing software, transcription systems, and electronic health records (EHRs).
• Ability to work independently with minimal supervision and manage multiple priorities while meeting deadlines.
• Strong attention to detail and commitment to documentation accuracy.
• Excellent written, verbal, and listening communication skills

Physical Requirements: Frequently sitting and typing for long periods of time. Occasionally lift up to 25 lbs. Ability to bend, stoop and reach. Sufficient hearing acuity to accurately transcribe and interpret dictated documentation.