Medical Records Technician (Full-Time)

Position Summary

The Health Information Management (HIM) Records Technician is responsible for understanding the principles and practices of acquiring, analyzing, maintaining, releasing and protecting medical information vital to providing quality patient care. These professionals are linked to physicians and information technology. They play an essential role bridging patients’ health information and payers, such as insurance companies, government and regulating agencies, and are a critical component of the electronic health record (EHR) workforce. Assembles patient health information including medical history, symptoms, examination results, diagnostic tests, treatment methods, and all other healthcare provider services. They organize and manage health information data by ensuring its quality, accuracy, accessibility, and security to ensure compliance with HIPAA, Joint Commission standards and medical staff by-laws and rules and regulations.

Essential Job Functions/Accountabilities

Routine use, maintenance and upkeep of Electronic Health Record (EHR) to ensure patient data is private, accurate and secure. Maintains and operates a variety of health record databases and HIM related applications, to collect, classify and analyze information. May assist providers in Cerner, Athena and/or other electronic system usage relative to medical record deficiency completion. Coordinates with clinicians, coding/billing and clinic support teams to provide completeness and accuracy. This may include documentation creation in the EHR, such as transcription.

Performs daily charge entry and/or verifies existing charges for services rendered with speed and accuracy. Understands and follows order entry rules and the use of modifiers based on services etc. May prepare electronic or paper copies of medical charts according to hospital policies and procedures consistent with HIPAA, Joint Commission, and Compliance Plan regulations; meets department/hospital guidelines for appropriate turnaround time of record processing. May process STAT requests and Third Party Requests.

Navigate and retrieve medical records from offsite and legacy systems. Retrieves discharged records from all units (inpatient, outpatient surgical and outpatient clinic) on a daily basis and verifies against daily discharge roster; Retrieves paper medical records or verifies availability of scanned medical records for review. Understands the physician deficiency process and can perform electronic entry and resolution of those deficiencies; runs deficiency reports by location and physician.

Performs various administrative duties, including, but not limited to, answering/forwarding telephone calls, faxing, typing, sorting mail and preparation of correspondence. Performs quality and chart order preparation prior to indexing into the EHR and performs quality check of electronic documents against the paper copy prior to destruction or chart correction as assigned; triages the patient portal supporting continuity of care.

Assists Supervisor with training and orientation of new personnel; assists supervisor with discharge not final billed reports; Communicates with appropriate hospital departments or external vendors for equipment maintenance as needed; performs other HIM job related functions for coverage.

Actively participates in departmental meetings and in-service education. Abides by the AHIMA Code of Ethics.

All other duties not specifically assigned.

Position Requirements

Education: College degree or progress towards degree preferred.

Experience: One (1) to Three (3) years of demonstrated experience in healthcare field or healthcare profession related to Health Information Management preferred; Proficient knowledge of an EHR required.

Technical Skills: Medical terminology knowledge; employee should demonstrate a cooperative behavior with colleagues and supervisors; the employee shall work well under pressure, meet multiple and sometimes competing deadlines; ability to organize and prioritize work; accuracy and speed is required and an ability to handle repetitive job and stay focused; moderate knowledge of PCs is required