HIM Operations Specialist I

Accurately upload/Index outside records using applicable software, routing documentation to the clinician as appropriate. Creates or selects the appropriate patient, encounter, and/or order while assigning the correct document type and description when indexing into the EHR.  

Incorporates internal and external clinical documentation from various electronic and paper sources via applicable software work queues, rounding, eDelivery or importing into the EHR according to HIM procedures while meeting established benchmarks for quality, accuracy, and productivity. Applies knowledge of medical terminology and nomenclature to accurately identify documentation needs based on patient service areas and level of service provided.   

Analyzes the content of the medical record for missing documentation and signatures and assign/edit medical record deficiencies by the responsible provider into the chart management system according to State and Federal regulations, such as Det Norski Veritas (DNV) or The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), all Medical Staff Bylaws and organizational policies.  Provides support and education to clinicians regarding record completion activities.  

Applies knowledge of medical terminology and nomenclature to accurately identify documentation needs based on patient service areas and level of service provided.  

Collaborates with Data integrity or other functional areas to ensure errors in documentation discovered are communicated for Chart Correction. Notifies appropriate leadership for quality review and privacy investigation.  

Ensures clarity, legibility, and position of the scanned documents are readable by the end-user or indicates best quality.  

Serves as point of contact for record completion support for clinicians and other providers.