Hot Springs Health

Clinical Documentation Technician

Job Description ______________________________________________________________________________

DEPARTMENT: Hot Springs Health Clinics

SUPERVISOR: HIM Manager

EMPLOYEE NAME:

APPROVED BY: Chief Financial Officer DATE: May 2026

______________________________________________________________________________

GENERAL:

In accordance with the Hot Springs Health Personnel Policy and Procedure Manual and the requirements of our accrediting bodies, the employee will: support the mission “Partnering with our community for quality health and healing”, the five core values “Ownership, Always Better Than Yesterday, Service First, Integrity, and Stewardship of Our Resources (OASIS)”. Our behavior creates our OASIS – a place where we can find safety, sustenance, and a pleasant change from the usual and vision of “being the provider and employer of choice in our region, providing the highest quality care and excelling as a teaching hospital in Wyoming.”

The established priorities of Quality, Service, Finance, People, and Growth will be utilized in decision making. Furthermore, the employee will demonstrate the ability to manage time, maintain a safe and clean environment; practice confidentiality; treat all persons with respect and professional courtesy; accept change; accept and provide constructive feedback; work as a team player and adhere to the infection control, fire and safety, disaster and hazardous waste policies. The employee must also demonstrate the competencies for their position and adhere to policies and procedures of their department. The employee will participate in quality improvement activities.

BEHAVIORAL REQUIREMENTS:

The following is a list of minimally required behaviors to assist the employee in partnering with our community:

Ownership

Accepts responsibility for actions, attitudes and health. Doing things right the first time, every time for excellent results. Accepts ownership of mistakes and takes constructive action to avoid repeating mistakes. Works with empowerment to the highest potential both as an individual and as part of the team. Unsatisfied with the status quo or just being “good.”

Always Better Than Yesterday

Performs at the highest level, always learning and looking for ways to improve, with an unwavering focus on safety. Celebrates and encourages the contributions of one another.

Constructively challenges the status quo by being flexible, adaptable and embracing change as a key element of our future success. Contributes to an environment that encourages creative thinking. Shares ideas and opinions and supports opportunities to learn and grow.

Service First

Doing our best every day to anticipate and exceed the expectations of patients, providers and co-workers. Understands excellence is the result of team effort. Creates legendary experiences.

Integrity

Does the right things. Consistently open, honest, trustworthy and ethical. Demonstrates respect for patients, their families, staff, providers and the community.

Stewardship of Our Resources

Strives to care wisely for our human, financial and natural resources. Strengthens HSH as a partner in the community.

POSITION STATUS:

This position is a non-exempt position. Generally expected to work 5 days a week.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. Process all patient related documents received in clinic via incoming fax, interoffice mail and postal service. Scan and upload into the patient’s electronic medical record (EMR) in a timely manner with attention to detail and accuracy. Support departmental operations by assisting with phones, document handling, and workflow needs.
2. Scan and upload documents in the electronic medical record (EMR)
3. Verify document accuracy by confirming patient identifiers including name, date of birth, and encounter number. Assigns documents to appropriate work queues and staff within the EMR
4. Maintain and organize RightFax folders and sort documents by intended recipient and location.
5. Prioritize document processing based on patient appointments and provider needs. Communicate effectively with providers, staff, and departments regarding documentation and workflow.
6. Facilitate secure distribution of documents to providers, nursing, and departments in a HIPAA compliant manner. Maintain strict confidentiality of patient information.
7. Manage outbound document workflows including requests for records from outside providers and facilities. Process and fulfill requests for medical records in accordance with regulatory requirements and organizational policy. Log and track release of information and continuation of care requests within the EMR system.
8. Work collaboratively with team members and assist other departments as needed.

The above duties are intended to describe the key aspects of the work performed by individual(s) assigned to this position. They are not to be construed as an exhaustive listing of requirements relative to the position. Therefore, the employee may be required to perform other duties as assigned.

QUALIFICATION REQUIREMENTS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE

1. High School Diploma or equivalent required.
2. 2-3 years of clinic or healthcare experience preferred.
3. Experience with Electronic Medical Records (EMR) preferred.
4. Strong verbal and written communication skills
5. Demonstrate good organizational and leadership abilities.
6. Basic computer skills required.
7. Ability to interact professionally with patients, providers, and staff.
8. Ability to work independently and within a team environment.

LANGUAGE SKILLS:

Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to effectively present information to top management, public groups, and/or boards of directors.

MATHEMATICAL SKILLS:

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and is knowledgeable in metric, apothecary and household measurements and can convert from one system to another.

REASONING ABILITY:

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Ability to modify care based on developmental/functional age of the patient as well as that of the patient’s ethnic background. Ability to apply problem solving and reasoning skills in daily situations as they occur.

CERTIFICATES, LICENSES, REGISTRATIONS:

• BLS

OTHER SKILLS AND ABILITIES:

Ability to act as a patient advocate. Ability to interact with patients, families, visitors and co-workers. Ability to interact assertively and tactfully when dealing with conflict and in group solving activities. Ability to demonstrate a professional, open minded approach in identifying problems and resolving problems/conflicts.

AGE SPECIFIC:

This position does not require hands-on care, however, incumbent must demonstrate understanding of how a patient’s chronological and developmental age influences his-her need for adaptations related to his/her abilities.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While filling this position, the employee must regularly lift and or move 10 pounds and occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this position include close vision, distance, vision, color vision, peripheral vision, and depth perception. This position also requires walking or standing to a significant degree. This position also requires reaching, handling, fingering, feeling, talking, hearing, stooping, bending, crouching, and working with equipment.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The employee is subject to inside and possibly outside weather conditions. The employee is also subject to exposure to blood and body fluids, proximity to moving mechanical parts, electrical shock, exposure to burns and radiant energy, exposure to explosives, exposure to toxic chemicals and biological agents.