The HIM/Admission Lead primary function is to be the main HIM associate while assisting with Admission’s as needed. The HIM/Admission Lead will also assist the Director in daily operations and tasks to ensure process are run smoothly which may include document imaging, analysis, audits, release of information and registering/escorting patients. The HIM/Admission Lead is a subject matter expert, and will be expected to provide training when needed, assist with day-to-day functions of the departments, and perform other tasks as assigned.

Essential Functions

Under the direction and supervision of the Director of Health Information Management and Admissions, the HIM/Admissions lead independently verifies all discharged patients have a health record; verify all necessary documentation is recorded in accordance with policies, procedures, state and federal guidelines; releases information according to state and federal guidelines; performs duties using appropriate and ethical behavior; provide input to department manager on performance and quality; identify and correct duplicate records and overlays. Additional responsibilities may include serving as a preceptor or education resource for employee questions, collaborating with leadership to ensure quality and accuracy and performing other related duties incidental to the work described herein.

Job Requirements

Required: High school diploma or equivalent 2-4 years of previous medical records experience

Preferred: RHIT certification, associate's degree in HIM or related field, Meditech Experience, Medical Terminology

Patient Interaction: Frequent

Infection Control: Initial and Ongoing training in dealing with infection control. Trainings could include but are not limited to, blood borne pathogens, bodily fluids and biohazardous materials as it applies to your daily work environment.

HIPAA: This position will have access to the following Protected Health Information in order to carry out the duties related to their position at Pawnee Valley based on the following criteria:

Primary - required (routine) to do the job

Secondary - required for the job but mostly be exception

None - no approved access

Description of Information Level

Primary:

Patient Demographic Information (information used to identify a person): Name, Date of Birth, Address, Race, Marital Status, Religion.

Financial Information/Insurance (information related to insurance, billing and payment): Billing Information, Payer Name, Payer ID, Account Balances, Plan Elements Covered, Payment Information, Payment Rates.

Clinical Information (information that describes a patient's health status): Diagnosis, Reports/Medical Notes, Test Results, Problem List, Procedures, History and Physical.

Secondary:

Coding Information (clinical information that is in (alpha) numeric format): ICD-10 Codes, Rev Codes, CPT Codes.