Health Information Management Clerk, Temporary

Description

About the Role

The Health Information Management (HIM) plays a vital role in ensuring the integrity, accuracy, and security of patient health information. As a key member of the HIM team, the HIM Clerk supports high quality patient care by maintaining complete, compliant, and accessible medical records. The HIM Clerk is responsible for record assembly, compilation, analysis, and participation in electronic and paper documentation workflows for each patient encounter. The Clerk also directly contributes to an efficient and positive patient and provider experience by ensuring timely record processing, protecting patient privacy, and maintaining compliance with regulatory standards.

How You’ll Make an Impact

As the HIM Clerk, you make a positive impact by ensuring patient health records are accurate, complete and readily available to support quality care. You help providers access the information they need by maintaining efficient documentation workflows across electronic and paper systems. You protect patient privacy and support compliance with regulatory standards, contributing to safe, timely, and effective care delivery.

Records Management and Processing

• Ensures all discharged patient records are received by reconciling against discharge lists for clinic and hospital encounters.
• Scans completed hospital and clinic records into the electronic medical record system.
• Reviews scanned documents for accuracy, ensuring correct placement, naming conventions, and metadata (date, time, subject), and corrects/rescans as needed.
• Coordinates Specialty Clinic schedules and ensures required documentation is received timely for coding.
• Transcribes physician and staff dictation accurately and within 48 hours, coordinating with outsourced transcription services as needed.
• Tracks completion of all transcription tasks.
• Facilitates internal and external coding queries and follows up as needed.
• Monitors and follows up on external coding queries weekly, using multiple outreach methods when necessary until responses have been communicated on at least three occasions.
• Purges, records, and/or scans outdated records prior to destruction in accordance with policy.

Clinical Documentation Analysis

• Reviews inpatient and outpatient medical records for completeness to support timely coding, ensuring required documentation (e.g., history and physical within 24 hours, discharge summary, and progress notes) is present, and generates provider-specific outstanding documentation lists.
• Identifies additional diagnoses from archived records, problem lists, or other documentation and provides findings to coders/HIM Coordinator to support complete abstraction.
• Verifies presence of treatment authorization and forwards encounters with missing authorizations to the Registration Supervisor.

Forms Control

• Evaluates existing forms and workflows, recommending and implementing improvements to enhance efficiency and user experience.
• Designs, develops, and updates electronic and paper forms bases on user requirements, ensuring clarity, consistency, and efficiency.
• Collaborates with departments to gather requirements, obtain feedback, and ensure forms meet operational needs and comply with organizational policies.
• Coordinates interdisciplinary forms committee meetings to review, standardize, and approve new, revised, or retired forms across departments.
• Maintains the central forms database, ensuring accurate version control, updates, and accessibility.

HIM Operations

• Assists in reviewing hospital medical records for completeness in accordance with established documentation requirements.
• Supports tracking of medical records throughout the completion process.
• Assists in assembling inpatient medical records into the established order for permanent filing.
• Performs additional duties as assigned to support departmental needs.

Requirements

Qualifications

• High school diploma or equivalent preferred.
• Computer and keyboarding skills and familiarity with medical terminology preferred.
• Related office experience my substitute for 1-2 months of on-the-job training.
• 3-6 month of on-the-job training provided to learn clinic and hospital record systems and comprehend pertinent medical terminology.

Who You Are

• Detail oriented with a strong commitment to accuracy in documentation and data entry. 
• Dependable team player who values confidentiality, structure, and consistency. 
• Adaptable and eager to learn new systems, standards, and processes.
• Professional and patient, with the ability to collaborate effectively across diverse teams and requests. 
• Self motivated and proactive, with the ability to manage tasks independently with minimal supervision.

Skills and Capabilities

• Proficiency in Windows-bases systems, Microsoft applications, scanning systems, and data entry tools. 
• Strong written and verbal communication skills. 
• Ability to prioritize tasks and maintain accuracy in a fast-paced environment. 
• Knowledge of HIPAA requirements, confidentiality standards, and release of information practices.

Position Details

Schedule: Part time, non exempt; 20-24 hours/week with regular and punctual attendance required.

Physical Requirements: Primarily seated computer work with some walking, bending, stooping, and lifting up to 25 lbs. Must be able to read, write, hear, and comprehend digitally captured, dictated information.

Equipment: Standard office equipment; computer/printer; scanner; transcriber, 10 key; fax/phone; copy machine.

Acknowledgment

I acknowledge that I have reviewed and understand the contents of this job description. I understand that this document may be revised at the organization’s discretion and does not constitute a contract of employment. Employment is at will and may be changed with or without notice, including but not limited to duties, location, compensation, benefits, or employment status.