ROI Medical Record Abstractor - Legal

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POST DATE 8/24/2016
END DATE 1/7/2017

Partners HealthCare(PHS) Boston, MA

Boston, MA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
High School Diploma or GED



As a not-for-profit organization, Partners HealthCare is committed to supporting patient care, research, teaching, and service to the community by leading innovation across our system. Founded by Brigham and Womens Hospital and Massachusetts General Hospital, Partners HealthCare supports a complete continuum of care including community and specialty hospitals, a managed care organization, a physician network, community health centers, home care and other health-related entities. Several of our hospitals are teaching affiliates of Harvard Medical School, and our system is a national leader in biomedical research.

Were focused on a people-first culture for our systems patients and our professional family. Thats why we provide our employees with more ways to achieve their potential. Partners HealthCare is committed to aligning our employees personal aspirations with projects that match their capabilities and creating a culture that empowers our managers to become trusted mentors. We support each member of our team to own their personal developmentand we recognize success at every step.

Our employees use the Partners HealthCare values to govern decisions, actions and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk, and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration.


The Release of Information Legal Specialist acts as the Keeper of the Records. Under the direction of the Supervisor/Release of Information, this position is responsible for abstracting, processing, and or preparing requests (for copy services), including but not limited to authorized judicial orders: court orders, subpoenas, search warrants, attorney, summons.

The Release of Information Legal Specialist is also responsible for the review and release of Protected Health Information (PHI) to the Department of Children and Families (DCF) and other authorized parties or legal entities in compliance with HITECH, HIPAA, General Laws of the Commonwealth of Massachusetts (MGL), Department of Public Health (DPH), and the policies of PHS. The ROI Legal Specialist will ensure a timely response to said judicial orders and requests and maintain the confidentiality and integrity of all information. Responsibilities include the ability to certify medical copies as true and complete. Responsibilities may also include processing other types of requests and follow up inquires related to patients, health care facilities and/or clinics, attorneys, insurance companies, and other properly authorized parties.


Responsible for the receipt of valid subpoenas, based on hospital policy and procedure. Requests court orders as required by law to release specifically protected or privileged information. Requests Notice of Taking Deposition, when necessary.
Interacts with attorneys and court representatives for clarification on requests as needed. Notifies other departments of the non-PHI subpoenas by fax, email or in person.
Accurately abstracts and/or prepares for copy service, subpoenaed records. Provides certification and assists with obtaining notarization of PHI records, based on the request.
Prepares paper and/or electronic copies of PHI in response to request types, including but not limited to court orders, subpoenas, attorney requests, insurance requests, continuing care requests and patient electronic requests. Must work well with outsourced vendor to complete relevant processes.
Accompanies original health records to courts and location of scheduled depositions, as required.
Testifies at Grand Jury Hearing, Court Trials, and attorney offices as to the authenticity of said health records containing PHI.
Analyzes health records for incidents that may lead to litigation against the hospital. Promptly notifies Risk Management of impending litigation.
Accurately abstract and screen health records for any specifically protected or privileged information that is not covered under a general authorization. If the request is invalid, compose correspondence letters in response to the rejected requests. Ability to manually and/or electronically redact sensitive information when required. When required, obtains proper authorization for records containing treatment of alcohol and drug abuse, sexual transmitted disease, genetic screening results, licensed social worker, AIDS/HIV, mental health, 42 CFR Part 2, domestic violence counseling, and sexual assault counseling, as defined by state and federal law, specifically stating the type of information that is being released.
Interprets and implements hospital and departmental policies and procedures related to the disclosure of specifically protected or privileged information, based on Massachusetts General Laws, Federal Public Health Laws, and HIPAA Regulatory Guidelines.
Arranges on-site depositions, with attorneys as needed and testifies as to the authenticity of documentation of the legal health record. Immediately notifies the supervisor of such depositions and is coordinated with Risk Management and Office of General Counsel.
Prepares records for outside copy service and fulfill requests by analyzing the requests and determining pertinent PHI based on the request. If the documentation is incomplete, works with respective HIM section to address the issue. May involve reaching directly to the provider/clinic for authorization to release PHI. Coordinates release of information requests with other PHS facilities if needed.
Forwards non-HIS requests to appropriate area(s) within the institution as needed. (e.g.: Risk Management, Central Billing Office, Human Resources, etc.) May be assigned special projects and other related duties based on the demands of the workflow and as defined by the supervisor or manager.
Releases health information phone requests by facsimile in emergency situations after verification and a call back is conducted to confirm requester. Under this type of pressure, must determine pertinent minimum necessary PHI required for the care of the patient.
Monitors and updates the PeC work queues on a daily basis and updates the comments accordingly documenting detailed timeline/issue. Provides daily updates to the supervisor that require management assistance.
Enters/scans/uploads all requests into PeC in an effort to track requests for retrieval purposes. Utilizes applicable legacy systems and PeC to retrieve PHI as needed.
Generates invoices for billable requests, according to department policies and procedures, and mail to requestors, while exercising appropriate due diligence of billable requests that are past due by generating and mailing action letters to requestors citing billable invoices that are past due.
Other duties assigned by the supervisor or manager.
Uses the Partners HealthCare values to govern decisions, actions and behaviors. These values guide how we get our work done: Patients, Affordability, Accountability & Service Commitment, Decisiveness, Innovation & Thoughtful Risk, and how we treat each other: Diversity & Inclusion, Integrity & Respect, Learning, Continuous Improvement & Personal Growth, Teamwork & Collaboration

High school diploma or equivalent required.
Associates degree, current or eligible accreditation by the American Health Information Management Association (AHIMA), Registered Health Information Technician or Administrator (RHIT/RHIA) preferred.
Knowledge of medical record and release of information procedures, at a level generally acquired during 2- 3 years experience preferred.
Comprehensive understanding of the components of a medical record, including how a record is maintained, organized and the retrieval of medical documentation in both paper and/or electronic format.
Comprehensive knowledge of medical