The Astria Health system, headquartered in the heart of the state of Washington’s wine country in the beautiful Yakima Valley, is the largest non-profit healthcare system based in Eastern Washington. Astria Health is the parent non-profit organization of Astria Sunnyside Hospital and Astria Toppenish Hospital and delivers care throughout the Valley through its Astria Health Hospitals and its Astria Ambulatory Care model focused on delivering the highest level of ambulatory and outpatient care in convenient locations in both the Lower and Upper Yakima Valley. Astria Ambulatory Care is designed to meet the changing lifestyles and diverse needs of those living and working throughout the region.

JOB SUMMARY

The HIM Tech Lead assembles and analyzes the medical record for completeness, accuracy, and correlation of the facts recorded and ensures that all diagnostic tests and procedures have been reported.

JOB QUALIFICATIONS

Knowledge, Skills & Abilities: Continuous ability to manage time effectively with organizational and prioritizing skills. Continuous ability to communicate effectively both orally and written. Ability to compile data, statistics, and reports. Continuous ability to work independently.

Education: High School Diploma or equivalent. Medical Terminology course.

Experience: Requires five years’ experience in all aspects of the Medical Record department.

• Retrieves, sorts, and scans records from various departments daily after verifying all documents are completed in entirety as per facility policy and procedure.
• Reviews patient records for timeliness, completeness, accuracy, and appropriateness of data.
  Organize and maintain data for clinical databases and registries.
• Track patient outcomes for quality assessment.
• Electronically record data for collection, storage, analysis, retrieval, and reporting.
  Maintain confidentiality of patients records.
• Interact and assist patients with review of their health records and/or release of their health information.
• Performs other duties as required.
• Identifies and analyzes records systems problems and proposes solutions to management to meet program and system requirements and organizational needs.
• Responds to health/medical record requests from providers, staff, or third-party agents in compliance with policies, laws, and regulations.
• Ensures security and confidentiality of resident and/or patient records in order to protect health information as per the Health Insurance Portability and Accountability Act (HIPAA) and other state or federal requirements.
• Interpret Revised Code of Washington (RCW) and Code of Federal Regulations (CFR) regarding protection/privacy of patient or resident health records.
• Performs comprehensive quality assurance and/or compliance audits on patient and/or resident records to ensure compliance with applicable policies, procedures, RCWs and/or CFRs; verifies Advance Beneficiary Notice (ABN) compliance.
• Abstracts data using two or more systems and prepares periodic narrative and statistical reports as related to health and/or medical records;
  Maintains awareness of current industry trends, best practices and benchmarks in order to provide technical guidance, feedback or training to medical providers and staff.
• Represents agency in court or hearing(s) regarding health and/or medical records, as required or requested.
• Creates and maintains electronic and physical files.
• Identifies and analyzes records systems problems and proposes solutions to management to meet program and system requirements and organizational needs.
• May monitor patient’s length of stay, severity of illness, and intensity of services to assure appropriate utilization of resources or explain the justification for admission, treatment, and length of stay.
• Designs manual, electronic and/or automated health records filing systems and/or forms to meet specialized requirements; schedules and coordinates the implementation of plans for both standard and specialized systems in consultation with management.
• Reviews patients' records for completeness and accuracy according to established standards and maintains consistency and accessibility of records.
• Collaborates with medical providers or other pertinent staff to resolve clinical documentation inaccuracies, and facilitates improvements and corrections when necessary.
• Employee can be depended upon to complete work in a timely, accurate, and thorough manner and is conscientious, about assignments.
• Excellent verbal and written communication skills.
• Detail orientated and ability to be self-motivated to prioritize and make decisions to complete duties in a timely manner.
• Ability to perform repetitious movement, including long periods of standing or sitting, along with the ability to stoop, bend, reach, step up and sit for extended periods of time.
• Ability to maintain patient and employee confidentiality.
• Ability to perform routine maintenance and basic maintenance of scanning equipment preferred.
• Proficient in the operation and use of computers and scanners including various software programs such as Cerner, Epic, word processing and spreadsheets.
• Ability to work in a team environment and to collaborate with a variety of professionals.
• Ability to work under pressure of deadlines.
• Knowledge of standard medical terminology, basic human anatomy and medical record format, content and medical documentation order preferred.
• Ability to examine a document and determine its proper placement within the paper or electronic record.
• Ability to examine the record and verify patient identification.
• Knowledge of indices and filing systems necessary to file, store, and retrieve information from paper and electronic record systems preferred (terminal digit filing preferred).
• Knowledge of: general health information management (medical records) guidelines, techniques, regulations; medical terminology; policies and procedures related to records management; office management procedures; confidentiality and privacy rules; records retention and destruction guidelines; filing; systems analysis.
• Ability to: analyze data for standardization; abstract information required to prepare statistical and other reporting; work effectively with staff, medical providers, and other affected parties; communicate clearly and effectively both orally and in written form; work cooperatively with professional and nonprofessional staff; draw conclusions from data; train technical, professional and other staff; lead other staff.

WORKING CONDITIONS & PHYSICAL REQUIREMENTS

Work is primarily performed in an office setting and is considered sedentary work. Sedentary work involves sitting most of the time. Walking and standing are required only occasionally. Requires exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Requires repetitive typing and key entry work, and computer work. Requires normal/corrected vision and hearing to normal range. Requires good manual and finger dexterity to operate computers, phones, and handle documents. The worker is not substantially exposed to adverse environmental conditions.