HIM Document Capture Specialist

Under the supervision of the HIM Operations Manager, the HIM Specialist supports the HIM Department by ensuring compliance with confidentiality and disclosure regulations. The role facilitates timely access to complete and accurate patient records, supports document capture processes (e.g., chart pickup, scanning, indexing), and maintains the integrity of the electronic health record.

This is not an exhaustive statement of duties, responsibilities, or requirements.  Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation.

• Reviews each document in assigned WQs for accuracy of document type and patient identification.

• Processes and verifies images meet the quality requirement and are indexed correctly before releasing and importing into the electronic legal medical record (ELMR).

• Poor quality documents are corrected or deleted from batch and marked for special scanning. Performs assigned quality control activities.

• Perform scanning and indexing quality reviews and report findings to management for inclusion in departmental KPI reporting.

• Train and educate staff on quality scanning and indexing, assigned as EMR superuser, as needed.

• Assist with retrieval of patient records and loose documents from the appropriate patient care units, scan documents and perform routine maintenance and cleaning on scanning equipment in accordance with department policy and procedures to ensure high quality images.

• Locates/identifies MRN and/or Encounter number for loose documents that come into HIM with unidentified MRN or encounter and write information onto the document to prepare for scanning.

• Sort and prep loose materials, verifying that like documents are grouped together, as needed.

• Demonstrates flexibility on shifting priorities and performs other related duties as assigned such as front reception area coverage, assists patient, patient’s family, and other third-party requestors with questions regarding copying/release of patient information, etc.  Provide customer service including phone support, walk-in assistance, and handling information requests for continuation of care, both internal and external, as needed.

• Practices proper safety techniques in accordance with Center and Departmental Policies and procedures. Responsible for reporting of employee/patient/visitor injuries or accidents, or other safety issues to the supervisor and in the occurrence notification system.

• Monitors and ensures compliance with all regulatory requirements, organizational standards, and policies and procedures related to area of responsibility. Identifies potential risk areas within area of responsibility and supports problem resolution process

Required Minimum Education:

• High School Diploma or equivalent

Required Minimum Certification:

• No professional certification is required.

Required Minimum Experience:

• Two years of previous experience in a Health Information Management environment in a hospital or large physician group.

• Customer service experience in healthcare

Required Minimum Skills:

• Basic Microsoft Office skills

• Must be able to type & operate a computer keyboard, multi-line phone, fax & copy machine

• Knowledge of medical terminology and health information systems

• Strong communication, critical thinking, and multitasking abilities

• Ability to work independently and interact professionally with diverse stakeholders

Preferred Qualifications/Experience:

• Three years healthcare experience in an acute care HIM Department

Physical Demands:

• Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time or exerting up to 15 pounds of force occasionally or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.

Working Conditions:  

• No potential for exposure to blood and body fluids.

The above statements are intended to describe the general nature and level of work performed by people assigned to this classification.  They are not intended to be an exhaustive list of all job duties performed by the personnel so classified.