Health Information Specialist
2 weeks ago
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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