Medical Records Technician

Position Summary:

The Medical Records Technician complies, processes, and maintains records of hospital and/or clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the healthcare system. The position processes, maintains, complies, and reports patient information for health requirements and standards. Technician will be responsible for the scanning, filing and Release of Information request, recording of hard-copy patient medical documents into an electronic patient records system. Chart Abstractions for CMS Quality Control and HIDI State Reporting are also the responsibility of the Medical Records Technician. The Medical Records Technician also maintains Process Improvement objectives to be reported in the PI meetings.

Essential Duties and Responsibilities:

The essential functions include, but are not limited to the following:

· Assembles contents of the medical record into established order for permanent filing

· Notes deficiencies to be completed by the physician or other professional staff

· Maintains follow up of records with deficiencies until the record is complete

· Upon discharge, assembles and reviews the medical record for completeness

· Insures receipt of all records of resident’s discharge from facility by checking the list of discharged patients

· Files completed medical records of discharged patients and retrieve any prior record for inclusion with current record

· Participates in on-going training and in-services, which allows for development and improvement of knowledge and skills

· Holds in confidence all information contained in the patient’s medical record and other documents pertaining to the resident

· Release of Information Request

· Complies with HIPPA rules and regulations

· Preparation and scanning of medical documentation into EHR system.

· CMS Quality Reporting of MR Abstractions have deadlines to meet so organizations skills are very important.

· HIDI State Reporting

· Process Improvement objectives are researched daily through MR charts and maintained for reporting in PI meetings.

Minimum Qualifications (Knowledge, Skills and Abilities)

• High School diploma or GED equivalent
• Read and understand medical terminology
• Three to six months related experience and/or training or equivalent combination of education and experience Two years of experience in a medical office environment Experience with scanning equipment
• Coding knowledge

Physical Demands and Work Environment

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made.

· The position occasionally requires sitting, standing and bending

· Occasional very light lifting, up to 20 pounds or an equivalent weight may be required

· May require dealing with violent or physically aggressive people

Note:

This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will posses the skills aptitudes and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship.

Pay: From $16.00 per hour

Expected hours: 40.0 per week

Work Location: In person

Salary : $16