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Health Information Specialist

Title: Health Information Specialist

Job Type: Full-time

Pay: $20.00 – $25.00 per hour

Expected hours: 40 per week


As a Health Information Technician, you will play a crucial role in managing and maintaining patient health records. Your primary responsibility will be to ensure the accuracy, accessibility, and security of electronic health records. You will work closely with healthcare providers to guarantee the proper documentation of patient information.


  • 401(k)
  • Dental insurance
  • Employee discount
  • Health insurance
  • Life insurance
  • Paid time off
  • Vision insurance


  • 8-hour shift
  • Day shift
  • Monday to Friday

Application Question(s):

  • Have you worked in Behavioral Health before?
  • Do you have exposure and have worked in different EHR/EMR systems?
  • Do you currently work in a high-volume, fast-paced setting?
  • Are you comfortable with Medical Record auditing according to payer policies and guidelines?


  • Medical records: 2 years (Required)

Work Location: Remote

Duties and Responsibilities

1. Conduct audits of clinical documentation to ensure accuracy, completeness, and compliance with medical necessity criteria and regulatory standards.

2. Review and analyze medical records, including progress notes, treatment plans, diagnostic tests, and discharge summaries, to determine adherence to documentation guidelines.

3. Communicate with healthcare facilities and providers to notify them of record requests, provide instructions for review, and clarify documentation requirements.

4. Inform accounts of level of care guidelines and medical necessity criteria expected for record submissions and notify accounts of any deficiencies in medical necessity or attendance documented in the records.

5. Prioritize record requests based on urgency, date requested, and type of request to ensure timely processing.

6. Utilize medical record checklists and audit tools to systematically review documentation and identify deficiencies

7. Download, collect, and file documentation from electronic medical record (EMR) systems or other sources as needed.

8. Prepare and organize clinical records for submission via email, fax, or priority mail to requesting parties.

9. Draft cover letters and prepare claim forms to accompany record submissions as necessary.

10. Maintain accurate records of all record submissions, including tracking numbers, submission dates, and any follow-up actions taken.

11. Collaborate with the billing department to communicate missing attendance and ensure corrected claims are submitted with the necessary documentation.

12. Report to supervisor regarding any recurring issues or significant deficiencies in clinical documentation.


Communication Skills: Clear and effective communication, both written and verbal, is essential for interacting with team members, healthcare providers, and external parties regarding medical record requests and other administrative matters.

Clinical Documentation Review: Ability to review and analyze clinical documentation for accuracy, completeness, and compliance with medical necessity criteria.

Auditing Skills: Proficiency in conducting audits of medical records and identifying deficiencies in documentation.

Attention to Detail: Given the sensitive nature of medical records and the importance of accuracy in processing requests and maintaining records, a high level of attention to detail is paramount.

Technical Proficiency: Competence in using relevant software applications, such as Microsoft Office suite and SharePoint, is necessary for email management, data entry, and document handling tasks essential to the role.

Organizational Skills: The ability to effectively organize and manage medical records, prioritize tasks, and meet deadlines is crucial for ensuring efficient workflow within the HIM department.

Record Management: Understanding of record management principles and practices, including accuracy, completeness, and confidentiality in maintaining medical records and documentation.
Chart Compilation: Compile medical charts as requested by MR (Medical Records) Specialists, Ensure all required documents and information are included in the compiled charts, and Maintain organization and confidentiality of patient records throughout the compilation process.
Chart Submission: Submit compiled medical charts on behalf of MR Specialists to requesting parties, Ensure timely and accurate submission of charts to meet deadlines and regulatory requirements, and Maintain communication with requesting parties to confirm receipt and address any inquiries related to submitted charts.

Time Management: Strong time management skills to prioritize tasks, meet deadlines, and follow up with accounts in a timely manner.
Teamwork: Ability to collaborate effectively with supervisors, colleagues, and external stakeholders to achieve common goals and objectives.

Adaptability: Flexibility to adapt to changing priorities, procedures, and requirements in a dynamic healthcare environment.

Industry Knowledge: Understanding and adherence to patient confidentiality regulations, such as HIPAA, is critical to maintaining the privacy and security of medical records and patient information.

Required: HIPAA Compliance – Demonstrated understanding of and commitment to maintaining strict adherence to HIPAA regulations and guidelines in all aspects of medical record handling, including data entry, communication, and record management.
Proficiency in Microsoft Products – Advanced proficiency in Microsoft Office suite (Word, Excel, Outlook) and SharePoint, with the ability to efficiently utilize these tools for email management, data entry, document handling, and other administrative tasks essential to the role.


Proficiency in electronic health record (EHR) systems such as KIPU, Sunwave, Alleva, etc.

Regulatory Compliance: Familiarity with healthcare regulatory requirements, including HIPAA regulations, Stark Law, Anti-Kickback Statute, and other relevant healthcare laws and regulations.

Auditing Skills: Proficiency in conducting audits of clinical documentation, with the ability to identify discrepancies, errors, and deficiencies.

Experience: Minimum of 1 year of experience in clinical documentation auditing with knowledge of medical coding. Experience in a behavioral healthcare setting or medical records department is highly desirable.

Knowledge of Clinical Documentation: Comprehensive understanding of clinical documentation requirements, including medical necessity criteria, level of care guidelines, and regulatory standards (e.g., CMS guidelines, HIPAA regulations).

Benefit Conditions:
– Competitive salary based on experience
– Comprehensive benefits package including health insurance and retirement plans
– Opportunities for professional development and continuing education
– Positive work environment with a supportive team

This position offers a rewarding opportunity to contribute to the efficient operation of healthcare facilities by ensuring the integrity of patient health information. If you are detail-oriented, have a passion for healthcare, and possess the necessary skills, we encourage you to apply for the Health Information Technician role.

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