Health Information Management Technician-Coding Specialist

Purpose: The Health Information Technician-Coding Specialist is responsible for retrospective review and analysis of patient records for accurate coding and documentation completion. assembling, organizing, maintaining and responding to requests for patient health information in accordance with applicable Federal, State and accrediting agencies’ requirements. 

Key Job Responsibility Areas 

1. Medical Coding and Documentation Analysis
2. Records Management
3. Miscellaneous

Detail of Key Job Responsibility Areas 

1. Medical Coding and Documentation Analysis
2. Performs audits on coded data for accuracy based on documentation in the medical record to ensure medical records are coded and billed in accordance with coding conventions, billing rules, Federal & State regulations. 
3. Prepares reports and analysis of data integrity findings with recommendations.
4. Works collaboratively with Clinic and Coding/Billing staff to develop education strategies to promote complete and accurate clinical documentation.
5. Assists in educating Providers on clinical documentation requirements to support accurate and complete coding. 

2. Records Management

1. Maintain paper and electronic medical records system
2. Must have knowledge of statutes governing health information management
3. Review records for completeness, accuracy and compliance with regulations
4. Confer with appropriate clinic staff to ensure patient records contain most updated patient information
5. Facilitate and maintain policy and procedures for release of patient information
6. Ensure timely and accurate transfer of medical records for patients transferring from practice.
7. Notes on EMR system patient transfer information, as appropriate.
8. Review and release medical records as needed and appropriate for referrals made by providers, as well as requests for records by authorized agencies.
9. Scan patient records sent from other providers and capture key information for EMR from scanned documents.
10. Responsible for storing PHI in a manner that protects the confidentiality of patients.
11. Schedule and pull charts as needed for special audits, peer reviews and other compliance reviews. 
12. Key administrator for granting staff access rights to RHIO, E-Partner, etc.
13. Maintain existing paper charts including creating, repairing and thinning charts in compliance with NYS Department of Health Regulations.
14. Process Inactive/Expired/Deceased Electronic Health Record and/or prepare paper patient records and send them to offsite storage facility.
15. Receive all patient forms to be filled out; fill out as much as possible, give to providers, track, and mail out in a timely manner. All forms will be scanned in electronic health system in patient’s charts.
16. Maintain and monitor Chart Sign In/Out process and offsite records tracking database.
17. Support Sr. Health Information Management Technician as required. 

3. Miscellaneous

1. Requires the ability and commitment to respect and support inclusiveness and diversity including but not limited to individuals of different backgrounds, cultures, races, ages, sexual orientations, gender identities or expressions, experiences, opinions, etc.
2. Requires individual demonstration of commitment to the One Trillium behaviors and business impacts and modeling them in the organization. 
3. Communicate effectively verbally and in writing with individuals at all levels in the organization calmly in situations which require a high degree of sensitivity, tact and diplomacy. 
4. Responsible for maintaining confidentiality of all patient, client, employee, protected and proprietary information.
5. Employees are accountable for meeting the performance standards of their departments and must participate as requested in compliance audits, process improvement and quality improvement plans. 
6. Other duties as assigned.

Qualifications

Associates degree in a health information management program and medical terminology, Certification by the American Association of Professional Coders (AAPC) required. Knowledge of medical office procedures, claims processing, preparing patient charts and basic computer skills. 

Physical Requirements

While performing the duties of this job the employee is required to stand, sit, walk, use hands to finger, handle, or feel; reach with hands and arms, talk and hear. Occasionally the employee must stoop, bend and lift or move up to 25 lbs. Specific vision abilities required include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus. 

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

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