HIM Clerk – Part Time

This position performs medical records services and duties for Critical Access Hospital. Processes admissions and discharges of patients including: Inpatient charts, Outpatient charts, Emergency services, Outpatient services.

Pay Scale: Part-Time, Non Exempt, Hourly, No Call, No Differentials

Department: Health information Management

Reports To: DIRECTOR OF MEDICAL RECORDS, DIRECTOR OF REVENUE CYCLE, CHIEF FINANCIAL OFFICER, CEO

Location: Seminole Hospital District

Primary Responsibilities

  • Inpatient Charts (MED, SUR, OB, NB, SWG) Outpatient Charts (OBS, OPS):
    • Reviews midnight census for Admits and Discharges. Verifies patient is in correct Service using Critical Access Hospital Division of Charts by Insurance by Service. Advises Business Office and Utilization Review of any discrepancies.
    • Places charts in Chart Order.
    • Performs Quantitative and Qualitative Analysis. Flags doctors and /or nurses for deficiencies. Reports to Quality Assurance for missing information. Checks for proper identification and proper reports attached.
    • Quality indicator done on all chars for QA reporting at end of month.
    • Chart Deficiency Report done for Clerk doing Doctor Deficiency List.
    • Chart Deficiency Maintenance and Chart Location Filled out in computer.
    • Transfers entered into log.
    • Prepares review sheet for Medical Staff Meeting.
    • Places charts in location for doctors and nursing to complete deficiencies, or to transcription for completion, or scanned to outsource coding.
    • Prints completed Coding Summaries for all Stay Types, stamps all Coding summaries, sends Coding Summaries to Business Office for charges with in 24 hours of printing summaries.
    • Receives Coding Summaries back from business office and Abstracts all Stay Types and places a finish date into CPSI Chart with in 24 hours.
    • Places Paper Record in the next appropriate location.
    • Places Record in Chart Location in CPSI
    • Final Check- after paper chart is placed in final check HIM clerk will thoroughly check record to make sure record is complete.
    • Once verified the paper chart is complete, the chart is scanned into CPSI, once scanned into CPSI and verified electronic chart is complete, paper chart is shredded.
    • Assists with set up of Medical Staff and Executive Medical Staff monthly.
  • Emergency Services (ER’s)
    • Verifies that all ER sheets are accounted for.
    • Scans ER’s to Incomplete ER Face Sheet for all Departments to work with until ER’s are complete.
    • Places ER’s in Chart Order
    • Performs Quantitative and Qualitative Analysis. Flags Doctors and or Nurses for Deficiencies. Reports to Quality Assurance for missing information. Checks for proper identification and proper reports attached.
    • Scans ER’s to Code Med for Coding.
    • Chart Deficiency Maintenance and Chart Location filled out in computer.
    • Transfers entered into log.
    • Prepares review sheet and List of charts for ER Committee Meeting.
    • Places ER charts in location for doctors and nursing to complete deficiencies, or to scanning Clerk for Final Scan.
    • When Doctors and/or nurses complete Deficiencies ER’s are routed back to clerk who does the need procedure to process.
    • End of Month retrieves ER’s for Medical Staff Meeting and ER’s for Trauma Coordinator.
  • Outpatients (OPT’s and NPT’s, Labs, Radiology, Respiratory Therapy, etc.)
    • Retrieve a list from Business Office of Daily OPT’s and NPT’s.
    • Check each account number for:
      • Doctor’s Orders
      • Verify that all Labs, Radiology, Respiratory exams ordered were done and results were scanned in.
      • Reports discrepancies to Business office and or Ancillary Department.
  • Treatments (TR’s)
    • Separated from ER’s every morning.
    • Verify that it is a Treatment and not and OPT or ER.
    • Places TR’s in Chart Order
    • Performs Quantitative and Qualitative Analysis. Flags Doctors and or Nurses for Deficiencies. Reports to Quality Assurance for missing information. Checks for proper identification and proper reports attached.
    • Scans TR’s to Code Med for Coding.
    • Chart Deficiency Maintenance and Chart Location filled out in computer.
    • Places TR’s in location for Doctors and/ or Nursing to complete deficiencies, or to scanning clerk for Final Scan
    • When Doctors and/or nurses complete Deficiencies, TR’s are routed back to clerk who does the need procedure to process.
  • Therapy Charts (Physical Therapy and Speech Therapy)
    • Scans Monthly Evaluations and Re-Evaluations to Code Med for Coding.
    • When Therapy Patient is discharged, all reports are scanned into CPSI.
    • Maintains Therapy Log.
  • Birth Certificates
    • Obtains Medical Data Worksheet form For Child’s Birth Certificate from Mother’s and or Newborn’s Chart.
    • Review and make sure all questions are filled out. If not, chart is sent to DON for rerouting to the nurse that needs to fill out that information.
    • Business Office Clerk fills out information on Mother, Father, and Baby. It is then scanned into the computer and reports are sent to HIM Clerk,
    • Match Medical Worksheet with information retrieved from Business Office.
    • Enter Medical Data into Baby’s Information set up in TER (Texas Electronic Registrar).
    • Check for AOP’s Acknowledgement of Paternity. If available, this form is faxed to the STATE.
    • Once all information is entered into T.E.R., Birth Certificates are Certified in T. E. R. and sent to the State.
    • Scan Medical Data into CPSI under the Newborn’s Account Number.
    • Maintain Birth Register in Computer System.
    • Death Register is also maintained in the Computer System.
  • Release Of Information
    • Review request receive by mail, fax, and email or HIM Director thoroughly and timely.
    • Checks release of information for signature and date and the ROI was not dated longer than 90 days old
    • Obtains patients information of all dates requested.
    • Completes Risk Management Assessment and have signed by HIM Director
    • Completes Quality Assurance Notice, Pending Litigation Medical Records Review
    • Completes courtesy letter to the physician and have signed by HIM Director
    • Completes True Copy of Medical Record Recorded and has signed by HIM Director and Hospital Admin.
    • Send information gathered to be reviewed by HIM Director, Risk Management, QA, and Hospital Admin.
    • Send completed request following HIPAA by mail, fax, or electronically timely with in 15 days of request.
    • Follows all Subpoena and Affidavit policy and procedures
  • Statistical Information (Monthly and Yearly Statistics)
    • Compiles Hospital Statistical Information for Administration on a Monthly and Yearly Basis.
    • Compiles OBS and OPS Log and Data
    • Compiles Totals on Transfer Log.
    • Compiles Medicare/Medicaid Log-Medicare, Medicare/Medicaid, Under Age 65 with Medicare, Medicaid, and Swing bed Logs. Compiles Totals on these logs for Administrative Statistics.
    • Compiles Units of Service Report by Department. Receives all Departmental Totals and Transfers totals into Report for Administration.
    • Upon request compiles AdHoc reports for Departments.
    • Monthly report to Physicians Ad Hocked with Admission and Discharge
    • Monday-Friday clerk goes to nurses station and compiles the first list of physician deficiencies.
    • Quality Assurance Sheet for charts filed incomplete. (Monthly).
    • Physician Problem List (Started in 2012 but not enough manpower to continue.)

Essential Functions

  • Assign work; plan and manage priorities.
  • Resolve insurance claim rejections/denials, and non-payment of claims by payors.
  • Identify trends in billing and follow-up, maintaining working knowledge of state and federal billing guidelines in order to identify ways in which our patients can expedite resolution of insurance accounts and identify delays in processing.
  • Responsible for drafting effective appeals to insurance companies for reimbursement of monies owed.
  • Responsible for maintaining daily account, follow-up work lists within department.
  • Ensure compliance when processing claims. in accordance with contracts and policies; as well as to adjudicate claims as appropriate.
  • Responsible for identifying, researching, and resolving credit balances, missing payments and unposted cash as it pertains to billing account follow-up.
  • Process, and maintain within expectation, all correspondence received from patients and insurance companies as it pertains to correct and timely billing of claims, and receipt of payment.
  • Responsible for handling patient disputes and submission of issues to coding for review to ensure organizational and revenue cycle processes are followed.
  • Communicates appropriately with insurance companies, patients, co-workers and supervisors.
  • Perform other duties as assigned.

Education and Experience Requirements

  • High School Graduate or equivalent
  • One year experience in an HIM office setting
  • Medical Terminology

Skill Requirements

  • Typing
  • Knowledge of computers, software programs (Microsoft Outlook, Word, Excel)
  • Knowledge of general clerical duties.
  • Adapts to change.

Job Related Factors

  • Communicates positively and respectfully to audience (coworkers, patients, physicians, and others)
  • Performs required tasks without prompting and adjusts appropriately to situations.
  • Adheres to the attendance policy.
  • Attends required meetings and in-services
  • Participates in Hospital District Safety Program and QA Programs
  • Uses time and resources wisely.
  • Maintains HIPAA, keeping patient and hospital confidentiality
  • Maintains adequate supplies of items needed to perform job, orders, or reports low items to supervisor.
  • Practices proper phone etiquette, identifying self and department.
  • Reports adverse events regarding patients, guests, or self to supervisor immediately.
  • Adapts to change.
  • Reads and Responds to Email for Department communication

Supervisory Responsibility: 

None

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.

  • manual dexterity
  • lifting/carrying >= 50 lbs.
  • walking
  • extended periods of sitting
  • pushing pulling
  • climbing
  • visual acuity
  • hearing acuity
  • repetitive motion
  • kneeling/bending

Work Conditions:

  • inside
  • occasional highly stressful

Hazards:

  • OHSA Blood Bourne Pathogens Class III

Types of Clients Served:

  • Neonate <1yr
  • Child/Pediatric 1-11 yrs
  • Adolescent 12-17yrs
  • Adult (18-55 yrs.)
  • Geriatric (>55 yrs.)

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