Health Information Assistant

The Health Information Assistant is responsible for physician order data entry, release of information, physician visitation audit, quarterly record audits and update diagnosis lists, admission order entry, diagnostic coding, and discharge analysis as necessary. Responsible for department oversight in the absence of the Health Information Director. Hours:
Monday - Friday 8am - 4:


Physician Visit audits ensuring compliance with federal and state regulations
Contact physician offices for progress notes
Request PHI from hospitals and/or other healthcare facilities
Conduct other audits as assigned
Conduct quarterly documentation audits prior to quarterly MDS
ICD Diagnostic Coding
Update diagnoses lists prior to the quarterly MDS.
Demonstrate coding proficiently and accurately
Code diagnosis lists upon admission when HIM director is not available
Physician visits
Maintain tracking of MD visits
Audit the records for physician visitation compliance
Notify physicians of upcoming visits
Report compliance to DNS and HIM Director
Release of Information
Respond to requests for information from insurance companies, attorneys, insurance companies and Medicare QIO.
Maintain confidentiality consistent with State and Federal regulations and HIPAA Privacy Standards.
Admission Procedures
Enter new admissions in clinical software as necessary when HI clerk is not available.
Record Retention/Maintenance
Scan items into appropriate location within electronic medical record.
Prepare records for storage with Iron Mountain storage. Request records as needed for readmissions and requests for information. Maintain inventory of stored records
Filing miscellaneous items into the medical record
Clean and thin charts regularly
Proactively provide admission information for weekend admissions
Provide reports as requested by C&R Leadership
Back up HIM Director/Clerk as requested
High school diploma or equivalent
One year experience required in long term care including experience with ICD coding, knowledge of clinical documentation, release of information, and EHR. Knowledge of ICD-10 preferred.
Credentialed as a Registered Health Information Technician (RHIT) preferred

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