Reviews medical records for completeness in compliance with the hospital’s bylaws, HFAP standards, federal and state requirements. Provides data support by performing medical record reviews and data entry, creating and maintaining spreadsheets, databases and data collection forms, compiling results into report and graphical presentations and performing data verification, validation and reporting to the required external reporting agencies.

• Files required information into proper medical record.
• Assembles patient medical records to release upon consent of patient or as allowed for treatment, payment and healthcare operations, and releases records according to policy.
• Immediately notifies HIM Manager if records have been disclosed inappropriately
• Retrieves old records from previous EHR and scans or sends to requestor
• Analyzes medical records for completeness and accuracy according to department and hospital policy and procedures
• Enters deficiencies into computer and keeps a current log of those deficiencies
• Performs audits as part of performance improvement on medical records when directed by the HIM Manager
• Assists in answering telephone and taking accurate messages
• Maintains hospital requirements, policies and standards on confidentiality
• Assists in retrieving medical records for physician completion and obtains signature if needed
• Possibility of on-call hours
• Responsible for completing all birth certificates and death certificates, which includes entering the data into the state website.
• Willing to accept additional assignments
• Must be able to keep up with workload. Be able to process a minimum of 20 medical records per day
• Training of other software interfaces for maintaining a complete medical record
• Maintains a good working relationship within the department and other departments
• Must comply with OSHA standards and universal precautions.

Job Requirements:

• Prefer associates degree in Health Information Administration or Technician, licensed nursing training or equivalent health care program
• Preferred: Two or more years of previous similar hospital or clinic experience
• Preferred: Knowledge of HFAP standards and state medical record requirements
• Preferred: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) preferred
• Prefer familiarity with medical record requirements of Nebraska and CMS.