HIM Specialist I

Position: Health Information Management Clerk
Reports to: Compliance Manager
Schedule: Full Time, Monday–Friday

Job Summary: The Health Information Management Clerk is responsible for supporting the daily operations of the Health Information coordinator (HIM) Department by ensuring the accuracy, reliability, organization, and timely availability of patient health information. This position performs a variety of clerical and HIM functions, including chart preparation, record assembly, chart analysis, filing, data entry, release of information, indexing, and retrieval of medical records. The HIM Clerk I maintains strict confidentiality of protected health information and works collaboratively with physicians, hospital staff, and other departments to support efficient patient care and regulatory compliance.

Essential Duties and Responsibilities:

- Collect and distribute the Daily Inpatient Census to appropriate departments.

- Collect previous-day outpatient records and Emergency Room dictation in accordance with departmental policies and procedures.

- Assemble patient encounters and prepare records for coding in a manner that facilitates an efficient and accurate coding process.

- Perform chart analysis in accordance with departmental policies and procedures for inpatient, observation, swing bed, and outpatient surgical records.

- Maintain and update the physician delinquent record list.

- Verify and enter appropriate discharge types into the electronic medical record system, including any required discharge notes.

- Enter and maintain information in department-specific registries.

- Perform data entry and other clerical functions as needed to support daily HIM operations.

- File inpatient reports and medical records in the appropriate patient record according to established procedures.

- Create new patient folders and records as necessary.

- Retrieve medical records for physicians, clinical staff, and other authorized personnel to support continuity of patient care, audits, and other approved activities.

- Answer and direct telephone calls in a professional and timely manner.

- Run reports as needed to support the daily operations of the HIM Department.

- Maintain strict confidentiality and security of all protected health information (PHI) in accordance with HIPAA, organizational policies, and applicable laws and regulations.

- Process Release of Information requests according to departmental and facility policies and procedures.

- Perform document indexing accurately and timely.

- Copy medical records and apply appropriate stamps or identifiers as required.

- Address envelopes and prepare medical information for mailing in accordance with established procedures.

- Operate microfiche reader/printer equipment as required.

- Provide coverage for other HIM clerical staff and assume assigned duties when other clerks are unavailable.

- Complete all required facility and departmental education, training, and competency requirements in a timely manner.

- Maintain awareness of current quality, privacy, security, and patient safety requirements and follow applicable policies and reporting procedures.

- Perform other duties as assigned by the Health Information Management Manager that are consistent with the scope and responsibilities of the position.

Qualifications

Skills & Requirements:

- High School Diploma or equivalent required.

- Previous hospital, healthcare, medical records, or general office experience preferred but not required.

- No professional license required.

- Excellent telephone etiquette and verbal and written communication skills.

- Above-average typing and computer skills with the ability to learn and utilize electronic health records and other information systems.

- Strong attention to detail and accuracy.

- Ability to organize and prioritize multiple tasks while meeting established deadlines.

- Ability to maintain strict confidentiality of patient information and exercise sound judgment when handling protected health information.

- Knowledge of basic medical terminology is preferred.

- Ability to work effectively and professionally with physicians, patients, hospital staff, and other members of the healthcare team.

- Ability to work independently while also functioning effectively as part of a team.

- Ability to follow established policies, procedures, and regulatory requirements.

- Strong organizational skills and attention to detail.