Health Information Specialist II

Under the direct supervision of the HIM Director, the Health Information Specialist II is responsible for reviewing, analyzing, organizing, preparing, and scanning medical records to ensure the accuracy, completeness, and accessibility of patient health information. Primary responsibilities include analyzing Emergency Department (ED) medical records for required documentation, identifying and reporting incomplete records, preparing incomplete chart lists, and scanning medical records into the appropriate electronic medical record system.

This position requires attention to detail, independent judgment, organizational skills, and the ability to maintain confidentiality while handling sensitive patient information. Performs additional duties and responsibilities as assigned by the HIM Director.

Reviews and analyzes Emergency Department medical records to ensure required documentation is present and complete. Identifies, documents, and reports deficiencies or missing information in patient medical records. Prepares and maintains incomplete medical record lists and distributes them to appropriate departments or personnel for follow-up.

Locates medical records and verifies that required documentation has been completed. Prepares, organizes, and scans medical records into the electronic health record system. Ensures scanned documents are uploaded to the correct patient medical record number, visit number, and electronic record section.

Reviews scanned documents for accuracy, completeness, and legibility. Maintains confidentiality and security of patient health information in accordance with HIPAA and organizational policies. Maintains an organized and efficient workflow to ensure medical records are processed in a timely manner.

Performs other duties as assigned by the HIM Director. Requirements High school diploma or equivalent; current high school students may be considered. On-the-job training provided; previous clerical, office, or medical records experience preferred.

Familiarity with general office equipment and computer applications. Ability to learn and follow established procedures and workflows. Strong attention to detail and organizational skills.

Ability to work independently and make sound decisions within established guidelines. Ability to work under pressure and meet deadlines. Demonstrates dependability, responsibility, loyalty, and dedication.

Maintains professional conduct and protects confidential patient information. Good verbal and written communication skills. Excellent customer service and interpersonal skills.