Health Information Associate

Description

 Northwell is the largest not-for-profit health system in the Northeast, serving residents of New York and Connecticut with 28 hospitals, more than 1,000 outpatient facilities, 22,000 nurses and over 20,000 physicians. Northwell cares for more than three million people annually in the New York metro area, including Long Island, the Hudson Valley, Connecticut and beyond, thanks to philanthropic support from our communities. Northwell is New York State’s largest private employer with over 104,000 employees — including members of Northwell Health Physician Partners — who are working to change health care for the better.

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  Job Responsibility - Chart Preparation and Scanning

 In order to ensure timely processing of the medical record, it must be validated that HIM is in receipt of all inpatient/ambulatory day surgery/emergency department patient records.  The medical record will be reviewed for poor original, items that cannot be scanned through the document feeder, patient identification on each document, and will group like documents in the appropriate order.  All patient records will be scanned into CDPI.  Daily workflow must be maintained, insuring that records are scanned in a timely and efficient manner to avoid delay in further processing.

• Retrieves all records of discharged patients from all units daily.
• Checks daily discharge log to ensure receipt of all records and follows up on records not received.
• Checks each patient record for poor originals and stamps with “poor original” stamp.
• Correctly identifies poor originals and stamps them appropriately.
• Prepares all documents by removing staples, paper clips, sticky notes, and rubber bands.
• Prepares all documents in date sequence from admission to date of discharge.
• Groups like document types together, places in page order and in date order correctly.
• Insure all pages front and back have appropriate patient identifier correctly.
• Patient Name
• Medical Record Number
• Date of Birth
• Copies all damaged documents so that they can go through the scanning process without difficulty.
• Removes any COLD fed documents from each record (for example:  transcribed reports, radiology reports, lab reports.)
• Assembles all documents in appropriate order as outlined in chart prep policy.
• Assembles chart in correct order.
• Ensures that all charts are assembled within required time frame.
• Performs scanning process according to procedure and within required time frame.
• Maintains appropriate setup for scanner to ensure optimal image results.
• Assigns batch label according to procedure.
• Identifies pages that did not scan well and flags for scanning on flatbed scanner
• Writes batch to correct work queue.
• Cleans scanner on a weekly basis according to instructions
• Places completed batches in appropriate area for indexing

• Job Responsibility – Quality/Validation of Scanned Documents

Responsible for assuring that all patient records and loose documents are scanned into CDPI with the highest level of quality possible.  Has responsibility for indexing all documents to the appropriate patient and for ensuring each document is assigned the appropriate document name.

• Reviews images scanned within 24 hours of scanning
• Identifies documents that are of poor quality
• Marks documents for rescanning
• Ensures that all scanned documents are positioned correctly. 
• Indexes documents to correct encounter and document type.
• Performs indexing process.
• Each document is indexed to the correct patient encounter
• Each document is assigned the correct document name
• Verifies that bar-coded documents are correctly indexed
• Verifies that all documents are in the correct date order
• Identifies when it is appropriate to split and merge documents.
• Splits and merges documents correctly.
• Correctly inserts pages/documents when and where appropriate.
• Correctly appends pages/documents when and where appropriate. 
• Writes each indexed batch to the appropriate queue according to workflow procedure
• Reviews work queue(s) daily and ensures timely processing of all assignments in the queues

• Job Responsibility – Chart Deficiency Analysis

To allow for timely completion of the medical record, each discharged patient’s record will be reviewed for incomplete or missing items, identify the responsible practitioner for each of these items, and link the deficiencies to the appropriate physician for completion. 

• Selects appropriate assignments for analysis from work queue.
• Reviews each record for missing documents, missing signatures or missing text according to procedure.
• Correctly identifies missing elements.
• Assigns deficiencies to physician(s) according to procedure.
• Links signature deficiencies for COLD fed documents to correct physician, if applicable.
• Correctly identifies when dictation has not been done and assigns to the correct physician.
• Maintains analysis turnaround time within required timeframe.
• Monitors reanalysis queue (physician decline queue) daily and reassigns deficiencies when appropriate.
• Performs reanalysis process within quality standard.
• Verifies physician dictation on the dictation system if physician indicates delinquent records have been dictated and dictated report is not in Cerner.
• Whenever possible, answers any questions the physicians may have about their deficiencies and how to access assignments/complete deficiencies in Cerner.  Or directs to appropriate person for clarification.
• Uses initiative and creativity to encourage physician compliance with chart completion policy
• Maintains incomplete record rate.  Goal is to have all charts completed within 30 days of discharge. 
• Generates physician notification letters according to policy.
• Maintains (creates/modifies) physician letter database.
• Provides weekly reports to the hospital departments on incomplete records and physician fines/suspensions according to procedure.

•  Job Responsibility – Birth Certificate Completion/Submission

Complete data collection on live births and fetal deaths and submit to NY State Department of Health’s Bureau of Vital Statistics and local Registrar.

• Identify all newborns (from 3M report) and transfer name into the HIM Vital Statistics logbook and maintain same. 
• Receive and review work booklet completed by mother/physician, determine if follow-up interview/phone call is required to finalize it. Access patient record to obtain additional required data to finalize.
• Collaborate with nursing and coding staff to validate data elements and diagnostic information, as needed; review chart to resolve discrepancies and/or to obtain missing data.
• Enter data into SPDS computer database to generate a paper birth certificate then print.
• Distribute printed certificate to appropriate obstetrician to sign.
• Mail signed certificate to local Registrar within 5 days of birth.
• File Electronic Birth Certificate worksheet in date order by month for future verification purposes.
• Log into SPDS and electronically transmit birth certificates to NYSDOH daily
• Handle authorized and assigned error corrections by contacting NYSDOH Bureau of Vital Statistics representative and request that they unlock the appropriate file to correct identified error.
• Access SPDS computer database using unlock number issued by representative and make necessary correction.  Print corrected birth certificate, obtain signature and resubmit to local registrar office.
• Verify accuracy and completion of paternity affidavit and attach to completed birth certificate and submit to local registrar.
• Accurately completes fetal death certificate as necessary to comply with NYSDOH regulations by accessing the patient record.  Distribute for physician signature.
• Forward original copy to Bureau of Vital Statistics – NYS DOH and carbon copy to local registrar within 72 hours of the time of death.
• Attend required educational sessions and seminars to remain abreast of process and regulatory

 changes.

•  Job Responsibility – Release of Information

Responsible for reviewing and processing requests for release of information for walk-ins and physician offices. 

• Date stamps all requests and verifies accuracy of requested information in terms of requestor and valid authorization for release of information per NYS/HIPAA regulations.
• Accesses computer application(s) to obtain demographic and visit information and enters request in ROI software for tracking purposes.
• Orders records in offsite storage to fulfill requests.
• Contacts ancillary departments for their records when needed to fulfill a subpoena.
• Responds to telephone calls and faxed requests from patients, physicians and other health care providers in a timely and courteous manner.
• Assists patients who walk in with the completion of the authorization form and verifies identity per department guidelines.

• Job Responsibility-Skilled Nursing Facility (NDH Employees only)

• Verifies receipt of all SNF discharged charts by reconciling the monthly census.
• Completes record assembly and analysis of SNF charts in accordance with state requirements.
• Assures the record is complete by notifying the providers of their incomplete records.
• Assures all SNF charts are filed complete in accordance with state requirements.

Education and Experience Requirements:

• High School diploma or equivalent experience.  Associate degree preferred.

• PREFER: Minimum of two (2) years medical record experience with basic knowledge of HIPAA.

Minimum Knowledge, Skills and Abilities Requirements:

• Proficient in Microsoft Office including Word, Excel, and Outlook
• Proficient Internet Navigation
• Strong attention to detail. 
• Fax / Copy machine
• Organized and has the ability to prioritize requests.

License, Registration, or Certification Requirements:

• N/A

Company: Putnam Hospital Center

Org Unit: 879

Department: Health Information Management

Exempt: No

Salary Range: $18.76 Hourly