Medical Record Specialist

• Assists the IT team in the deployment of new applications and enhancements to existing applications by testing new document types and workflows.

• Performs chart identity reviews and merges duplicate charts. Adds identity and chart advisories to the EHR.

• Ensures advance care documents contain accurate and valid data before uploading them to the EHR.

• Retrieves, sorts and prepares medical record documents for scanning and indexing.

• Preps, scans and indexes patient financial and billing documents in support of revenue cycle activities.

• Uploads clinical documents to the EHR or document imaging software which are received in a variety of electronic methods.

• Performs Quality Assurance of scanned and uploaded images.

• Retrieves and releases patient information to patients, families, providers and other requestors in accordance with HIPAA; State and Federal regulations and laws; and organizational policy. Utilizes a variety of means to deliver patient information including mail, fax, email, patient portal and in-person.

• Works with radiology and cardiology images and systems, uploading to digital storage systems. Sends or produces CD copies of digital images to support continuing care and release of information requests.

• Analyzes, monitors and assures completion of patient record documentation by providers and other clinical staff. Provides assistance as needed.

• Performs various audits, including provider documentation. Distributes notifications and reports to providers, clinical leaders and others. Contacts provider and provider offices to communicate completion status and privilege suspension.

• Performs chart corrections and quality assurance audits for documentation scanned into the EHR.

• Answers all phone and fax inquiries to the department from internal and external customers.

• Assists in orientation, onboarding and training of new staff members in the department.

• Meets or exceeds established HIM Dept. productivity and quality goals.

The HIM Specialist is responsible for maintaining personal health information of Carle patients through scanning, processing and reviewing medical records in a manner consistent with medical, administrative, ethical, legal and regulatory requirements. The HIM Specialist will perform a variety of moderately complex tasks while maintaining a high level of confidentiality and quality. The HIM Specialist maintains the integrity of the legal health record so complete and accurate records are available for patient care and business use in a timely manner.