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Positions within Health Information Management
Clerical Data Abstractor
Files and scan documents in the paper and/or electronic record to assure that clinical information is available for patient care. Responds to telephone requests and retrieves records for patient care purposes. Interacts efficiently and effectively with intradepartmental and interdepartmental staff.
Clerical Data Processor
Responsible for the dissemination and processing of all transcribed reports, and memos regarding delinquent open encounters in accordance to the established procedures in a timely manner for the Health Information Management, Transcription Section.
Clinical Data Abstractor
Abstracts & scans clinical data (Lab, Medical Imaging, & Diagnostic test results) from the hard copy medical record to the Epic Care computerized electronic medical record (EMR) accurately and in a timely manner.
Inpatient Coders
Responsible for the proper coding and abstracting of all hospital accounts(inpatient, observation, out patient surgery, emergency services, and hospital outpatient visits) according to established ICD-9-CM and CPT coding guidelines.
RHIAs and RHITs are skilled in the collection, interpretation, and analysis of patient data for the purpose of improving patient care and controlling costs. They ensure the quality of medical records by verifying their completeness, accuracy, and proper entry into computer systems. They often specialize in coding diagnoses and procedures in patient records for reimbursement and research. They also may serve as cancer registrars which entails compiling and maintaining data on cancer patients. Additionally, they receive the training necessary to assume managerial positions related to these functions. RHIAs and RHITs interact with all levels of an organization-clinical, financial, administrative-that employ patient data in decision making and every day operations.
Release of Information Specialist
Protects the confidential nature of the medical record when responding to requests for release of medical information in the daily contact with physicians, their offices, health care and rehabilitation facilities, attorneys, insurance companies, patients, law enforcement agencies, interdepartmental and intradepartmental personnel and all other requesters for patient health information. Facilitate the process for all requests for protected health information (PHI) received in the Health Information Department.
Transcription
Transcribing reports timely and according to acceptable standards of quality by maintaining an accuracy rate of 99%, using the guidelines as forth by the American Association of Medical Transcription (AAMT).
