Health Information Specialist

Location

Huntersville, NC | United States

Job description

Job Summary:

Responsible for managing patient’s health records and history including helping conduct audits, gathering and filing patient information and processing discharge papers. Responsible for the release of information to patients, healthcare facilities and other entities while following all laws and regulations including HIPAA.

Requirements:

• Documented knowledge of medical terminology, anatomy and physiology, pharmaceuticals and the pathology of disease
• Documented knowledge of skills to code diseases, abstract data from the records, compile statistics and census reports and maintain secondary records, such as indexes, logs and registers; mental health coding preferred
• Bachelor’s degree in medical record science or medical record administration from an appropriately accredited institution, or completion of a medical record technician program an appropriately accredited institution and two years of experience in medical record work; or an equivalent combination of education and experience
• Knowledge of North Carolina laws, pertinent federal, state, and local regulations governing records and reports of medical care, vital statistics, and diseases including HIPAA
• Ability to perform quantitative reviews and audits
• Excellent verbal and written communication skills
• Strong data entry skills
• Superior organizational skills
• Attention to detail and accuracy
• Knowledge and skill in the use of a scanner and fax (efax)

Key Responsibilities:

• Manages and prepares electronic health record (EHR - Opus) and gathers information, including insurance information, and documents from patients
• Directs and evaluates quality control over the EHR
• Responsible for the day-to-day management of the EHR system for CYM
• Observes confidentiality and safeguards all patient related information
• Ensures that the electronic medical records are organized, accurate and complete
• Responsible for coordinating the release of medical information to insurance companies, lawyers, state and federal agencies
• Responsible for the processing of subpoenas and court orders, at the direction of the Clinical Manager/Director
• Verifies authorizations in accordance with program policies and procedures and state and federal laws
• Assigns the correct medical codes to data
• Transfers data into the facility’s EHR (Opus)
• Processes the records for admitting and discharging patients
• Prepares invoices
• Enters data, scans, files, faxes, handles medical records release and general miscellaneous office duties
• Maintains provider contact information
• Assists in the revision and/or generation of forms to be kept as part of the permanent medical record

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