Lead Health Information Management Specialist

San Marcos, CA

Full Time

Administration

Mid Level

TrueCare is a trusted healthcare provider serving San Diego and Riverside Counties, offering compassionate and comprehensive care to underserved communities. We are committed to making healthcare accessible to everyone, regardless of income or insurance status. With a focus on culturally sensitive, affordable services, TrueCare aims to improve the health of diverse communities. Our vision is to be the premier healthcare provider in the region, delivering exceptional patient experiences through innovative, integrated care.

The Lead Health Information Management (HIM) Specialist plays a critical role in maintaining, organizing, and protecting healthcare data to ensure its accuracy, integrity, confidentiality, and accessibility. With leadership from the HIM Director, this role will provide daily guidance, task oversight, and training support to HIM Specialists. The Lead HIM Specialist will lead internal audit and compliance reviews while also performing HIM Specialist duties as needed to support department operations and will support MyChart and Digital Health Ambassador program needs as directed. This position ensures compliance with regulatory requirements and facilitates efficient recordkeeping to support high-quality patient care and operational efficiency. This role also ensures confidentiality, security, accuracy, and timely delivery of health information to authorized parties, supporting healthcare operations and patient care. This includes managing the processing, tracking, and fulfillment of requests for medical records whether performed directly within the organization or by contracted vendor management partner.

Essential Functions:

Resource Management: Provide daily oversight and serve as a resource for HIM staff, including task delegation and workflow monitoring to ensure balanced workloads and timely and accurate completion of assignments.

Monitor work queues, productivity, and quality of team output.
Identify performance gaps and recommend process improvements while ensuring departmental goals are met.
Support onboarding and ongoing training of HIM Specialists
Resolve escalated issues as needed.

Auditing and Quality Control: Participate in external and internal audits and compliance reviews. Prepare reports and share findings with leadership to support continuous improvement.

Lead internal audit practices and perform quality assurance by assisting with periodic audits of records for accuracy and completeness.
Ensure all released information is complete, accurate, and aligned with applicable standards and regulations.

Ensure deadlines are met and aligned with regulatory or other department practice standards.

Health Records Maintenance: In accordance with organizational policy and department guidelines, maintain, organize, and secure patient health records, ensuring data accuracy and completeness in electronic health record (EHR) system.

Compliance and Standards: Ensure compliance with legal, regulatory (state & federal), and accreditation standards, such as HRSA requirements.

Data Integrity: Regularly audit health information for accuracy, consistency, and timeliness, correcting discrepancies as needed.

Scanning and Indexing: Scan and index documents into the EHR, ensuring timely and accurate availability of information. Key performance standards are as follows:

Volume management: Hourly rate of 100-125 pages/hour is baseline measure, depending on complexity and equipment efficiency.
Accuracy rate: Indexing accuracy rate of 98-100% is standard for correctly indexing scanned documents into the appropriate EHR section.
Timeliness: Indexing should be completed within 24 hours of receipt to ensure immediate accessibility for clinical staff.

Technology Utilization: Utilize EHR and related HIM systems and software.

Monitor and manage documentation management, electronic fax, EHR and other related system work queues timely in accordance with practice standards.
Closely monitor the Health Information Department scanning and fax machine
queues, and sort and process incoming faxes.
Assure information and relevant details are present for documentation received in accordance with department guidelines.
Review content received for duplicates and assess image to ensure best quality.
Monitor and process electronic tasks sent through the Electronic Health Record (EHR) system regarding PHI daily and in accordance with department guidelines.
Identify errors and facilitate corrections.
Retrieve documentation from third party portals; communicate with third party vendors as necessary to ensure complete and accurate document retrieval.
Review reports and complete work associated with each report, linking/closing associated orders and referrals in the EHR.

Process Requests: With oversight from Director and/or Compliance Office, follow documented procedures and guidelines, review, validate, and respond to requests for medical records from patients, healthcare providers, authorized stakeholders, and third parties. Ensure proper authorization and compliance with HIPAA and other privacy laws.

Record Management: Utilize electronic health record (EHR) systems to retrieve and manage data. Maintain accurate records of all release transactions and correspondence.

Customer Service: Respond to patient or provider inquiries about medical records in a professional and courteous manner. Respond to patient and other inquiries regarding the status of requests and address concerns related to release of information processes. Provide support, as directed, to MyChart and Digital Health Ambassador program.

Compliance and Privacy: Protect patient confidentiality and adhere to privacy and security policies.

Required Qualifications:

High school diploma or equivalent.
Two (2) years of professional work experience in a HIM department.
Proficiency with electronic health record system
Proficiency with Microsoft Office software, including Word, Excel, Outlook, and Teams.
Understanding of HIPAA Privacy and Security Rule.

Desired Qualifications

Associate’s degree in health information technology, management, or related field.
Two (2) years of health information management related experience and demonstrated understanding of required knowledge, skills and abilities.
Registered Health Information Technician (RHIT) certification.
Bilingual in English and Spanish.
Knowledge of medical terminology.
Experience working in a healthcare environment and with Electronic Health/Medical Record systems.

The pay range for this role is $23 - $32.20 on a hourly basis.

TrueCare is committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of any characteristic protected by applicable federal, state, or local law. Our goal is to support all team members recruited or employed here.

Pay transparency: If you are hired at TrueCare, your salary will be determined based on factors such as education, knowledge, skills, and experience. In addition to those factors, we believe in the importance of pay equity and consider the internal equity of our current team members when determining an offer.

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