HEALTH INFO MGMT TECH -

UNM Hospital; Albuquerque (NM); On-site; USD 42,000 - 56,000; Full time

Job summary

UNM Hospital is seeking a detail-oriented HIM/Medical Records Specialist to manage essential clerical functions across Release of Information and EHR entry. You will verify record completeness, conduct quality checks, and coordinate ROI requests with HIPAA compliance.

Responsibilities include scanning and validating documents, MPI updates, and supporting offsite record handling. The role requires at least 2 years in HIM/medical records, an Associate Degree, and familiarity with Cerner.

Qualifications

• Requires 2 years HIM/medical records experience.
• Experience following HIPAA guidelines and legal requirements.
• Familiarity with electronic health records (EHR) and chart management.

Responsibilities

• Create and maintain daily records of work performed.
• Perform chart analysis to ensure CMS/TJC documentation compliance.
• Process ROI requests and handle PHI disclosures with proper signatures.

Skills

Attention to detail

Communication skills

HIPAA knowledge

Education

Associate Degree

Bachelor's Degree

Tools

Cerner

Job description

Compensation Disclaimer

Compensation for this role is based on a number of factors, including but not limited to experience, education, and other business and organizational considerations.

Department: Medical Records/Support Svcs - UH

FTE: 1.00

Full Time

Shift: Days

Position Summary:

Responsible for all required clerical HIM functions and workflow within all areas including Release of Information; coordinates all tasks related to ensuring record completion. Preps and scans documents according to procedure to meet scanning timeliness and productivity. Performs quality checks of scanned documents and final validation of paper documents prior to committing to the electronic health record (EHR). Processes requests for medical records ensuring disclosures follow HIPAA guidelines and necessary requirements. Release of Information (ROI) functions include assisting customers in the reception area, processing all types of requests including continuing care, attorney, insurance, disability, subpoenas, Recovery Audit Contractor (RACS) and other requests received to obtain medical records. Electronically processes and tracks RAC, ADR and third party payer requests. Uploads images and performs film library functions. Processes pended transcription documents, problem solves missing transcription, reviews medical records for completeness and assigns provider documentation deficiencies in the EHR (CERNER). Tech II staff ensure documentation is in the correct location within the legal health record (LHR), communicate with providers to complete and/or dictate missing reports required for medical record completion and resolve provider documentation issues within the EHR. Perform Master Patient Index (MPI) management, revising/updating patient demographic information in the LHR. Researches and merges duplicate medical record numbers, combines FINS, complete trauma & stroke alerts, investigates encounter issues as assigned. Assists in coordinating records sent/retrieved from offsite storage. Analyzes assigned documentation criteria to report compliance statistics and data. Processes amendment requests. Required to float as assigned. Adherence to Hospitals and departmental policies and procedures is required. No patient care assignment.

Detailed Responsibilities:

• RECORDS - Create and maintain daily records of work performed
• QUALITY - Works as part of the team to identify process issues and report identified problems with any assigned function
• COMMUNICATION – As needed for coverage, answers all front desk calls and assist in providing coverage for walk-in patients and customers; provides requestors with authorization forms and ensures proper completion of authorizations are present prior to release of protected health information (PHI)
• CONFIDENTIALITY – Maintains medical records confidentiality and legal requirements
• ANALYSIS/COORDINATION - Completes chart analysis of all discharged medical records for inpatient, day surgery, and observation discharges; reviews H&Ps, Operative Reports, and Discharge Summaries to ensure they meet CMS/TJC documentation requirements; assignment of provider deficiencies when appropriate documents are missing or not authenticated per medical staff rules, regulations, and department guidelines; as well as communication with providers about incomplete/delinquent records; assist with ROI requests as needed
• EDUCATION – Assists with notification to providers for incomplete/delinquent records and/or transcription management
• DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
• TIMELINESS - Process all requests for information in accordance to federal, state and regulatory timeliness guidelines. Complete all reviews and documentation processing within established timeliness standards
• REVIEWS - Completes chart analysis of all discharged medical records for inpatient, day surgery, and observation discharges. Reviews H&Ps, Operative Reports, and Discharge Summaries to ensure they meet The Centers for Medicare and Medicaid Services (CMS) The Joint Commission (TJC) documentation requirements. Assignment of provider deficiencies when appropriate documents are missing or not authenticated per medical staff rules, regulations, and department guidelines
• INFORMATION REQUESTS - Processes all requests and inquiries for protected health information, dispersing the information with accountability to all regulatory entities and according to the facility’s policy and procedures; obtain proper signatures for release of information in order to comply with disclosure requirements in accordance with federal and state regulations; invoices, records and processes funds received from requesters
• PPOLICIES AND PROCEDURES - Ensures institutional policies and procedures for administration and maintenance of medical records are adhered to
• DATA – Use electronic medical records and supporting applications to retrieve necessary data for disclosures is required
• CUSTOMER SERVICE - Responds to patient and department requests for demographic changes in a timely manner; ensures customer issues are appropriately resolved; demonstrate positive customer relations; as needed for coverage of ROI functions, assists patients and families in completing required forms, locating documents, and referring them to the appropriate services and resources; processes urgent provider requests for protected health information in order to continue patient care

Qualifications

Education:

Essential:

• Associate Degree

Nonessential:

• Bachelor's Degree

Education specialization:

Essential:

• Related Discipline

Nonessential:

• Related Discipline

Experience:

Essential:

2 years HIM/medical records experience

Credentials:

Nonessential:

• Registered Health Information Technician

Physical Conditions:

Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Essential:

Working conditions:

• No or min hazard, physical risk, office environment