Medical Records Technician (46146)

Position will be based in either West Liberty OR Xenia. Candidate will be able to choose location upon hiring.

Position Summary:

Medical Records Technicians protect clients' rights to privacy by ensuring all record requests are processed in compliance with authorization standards, the Health Insurance Portability and Accountability Act of 1996, the Code of Federal Regulations (42 CFR Part 2), and all other applicable federal, state, and local laws. This role is essential to client care and health management services, prioritizing customer service, collaboration, and confidentiality.

Key Responsibilities:

1. Authorization for Release of Information rules and requirements.
   • Each staff member will be responsible for understanding, complying with, and following all Authorization for Release of Information rules and requirements to ensure proper completion of authorizations. Each authorization must contain all elements defined in TCN’s Release of Information/Privacy policy MR-001.
2. Identify and Return Invalid Authorization for Release of Information forms which do not meet the requirements identified under MR-001.
   • Complete Release of Information missing information letter by documenting the reason for the document being invalid in writing.
   • Print, sign, and send release of information missing information letter to requestor with invalid release of information, and a blank release of information for completion.
   • If the document is being sent by postal mail, provide a stamped return envelope with the request.
   • Upload a copy of the release of information missing information letter and invalid release of information into the Electronic Health Record.
   • If appropriate, contact the client to obtain a corrected release of information.
3. Log all records released in the client Electronic Health Record. The information below is required to be logged for all information released.
   • Requestor Name
   • Where was the information released to?
   • Date of request
   • Date information released.
   • Route of disclosure
   • Information released.
   • Purpose statement
4. Process requests for records received by phone, in-person, fax, or email according to the following schedule:
   • Emergency Requests involving immediate emergency care of patient: immediate processing.
   • Priority requests pertaining to current care of patient: within three (3) business days.
   • Patient request for access to own record: within thirty (30) business days.
   • Subpoenas and depositions: as required.
   • All other requests: within ten (10) business days.
   • Questionnaires for therapist/doctor” within ten (10) business days after next client appointment.
     • Gather information and assist client/requestor to determine what records will meet the purpose of the request following minimum necessary rules.
     • Complete release of information
     • If client is not present, determine how release of information will be signed (in-person or DocuSign)
     • Email treating providers to obtain permission to release requested information.
     • If information is not able to be released, follow denial of records request Access to Personal Health Information policy & procedures.
     • Gather client records to process request for records.
     • Upload authorization for release of information into Electronic Health Record
     • Upload request for records into client Electronic Health Record
     • Complete Release Invoice/Tracking document
     • Send records to client/requestor by secure email, postal mail, or to front office for pick-up.
       • If records are picked up, complete outreach to client and coordinate pick-up with support staff.
5. DocuSign (sending)
   • The DocuSign recipient must provide verbal authorization to receive items electronically and to sign the documents electronically prior to the document being sent for signature. The signature options are email, SMS, or both.
   • Locate the document which needs signed by the client/guardian.
     • If a Carelogic document, open the document which needs to be signed by clicking on the document line, not report.
     • Ensure document has been signed by all TCN staff members prior to pulling document for client/guardian signature.
     • Ensure a signatory is selected on the document to be signed. The document may need to be signed by a client, guardian, or both. If no signatory is selected, select the names of those who must sign the document in the signatory dropdown.
     • Click Report to open the document as a PDF.
     • Click Print, change printer to Adobe PDF, Click Print. Save the document on the secure network drive.
     • If the document being sent is an authorization for release of information, email #CarelogicIssues to request the unsigned document to be deleted from the client ECR after the document has been saved.
   • Open DocuSign and log into your individual account.
   • Upload the document to be signed into the document field.
   • Add recipients.
     • Recipient Name
       • If the document is being sent to one person, enter the email address or SMS number of the person to sign the document.
       • If the document is being sent to more than one person, enter separate email addresses or SMS number for each recipient.
       • If the document needs to be signed by two separate people with the same email address or SMS number, enter each recipient separately with different names and the same email address or SMS number.
       • Each recipient will receive a separate notification for signature.
   • Add subject of the email or text message (i.e., Authorization for Release of Information)
   • Add email or text message (i.e., You will receive two separate requests for signatures. The first request will be to obtain your signature as John’s guardian, the second request will be to obtain John’s signature.)
   • Click Next, the document that needs signed will appear.
   • Drag and drop the required field onto the document (i.e., signature and date signed) requiring a signature and/or date.
   • If two individuals will sign, change the signer at the top of the form and drag/drop the next signer fields (signature and date).
   • Once all fields have been entered, click send to send the document(s) for signature.
6. DocuSign (completed documents)
   • Once the document is fully signed, you will receive an email that the document has been signed with a link to view the document.
   • Use the link to sign into your DocuSign account.
   • View the document to ensure the document is signed correctly.
   • Click Print, save as PDF.
   • Save the document.
   • Upload the document into the appropriate client ECR.
7. Follow Up DocuSign requests.
   • Log into DocuSign and access the Manage screen to review outstanding document requests.
   • DocuSign will automatically send reminders for signatures every three (3) days.
   • A reminder may be manually sent by navigating to DocuSign > Manage > Waiting for Others > locate the document and click Resend to send a reminder.
   • If a client/guardian does not sign the document within two (2) weeks, the document should be printed, the DocuSign request should be voided, and the document should be sent to the client/guardian by postal mail to obtain the required signature(s).
     • Complete guardian letter, print, and sign.
     • Mail letter and document to be signed to client/guardian with a stamped return envelope.
     • Scan copy of letter and document to be signed, if applicable, into client ECR.
   • Add message board message to client ECR to indicate “all documents must be signed in person or by postal mail, client/guardian does not respond to DocuSign requests.”  
8. Send Referrals/Orders to Outside Entities
   • Contact the outside entity to determine if a specific referral form is necessary.
   • Obtain referral form or Outpatient Order from provider, if necessary
   • Review referral to determine if records must be sent with referral.
   • Verify Release of Information
   • Fax/Mail Referral, Records, and Release of Information
   • Complete Release Invoice/Tracking Document in Electronic Health Record
   • Scan Referral form with fax confirmation sheet, if applicable, into client Electronic Health Record.
9. Faxage
   • Log into faxage daily.
   • Print or save incoming faxes.
   • Review fax to determine nature of fax.
   • Distribute faxes to appropriate recipients.
   • Protected Health Information received through fax.
     • Look up clients in Electronic Health Information to determine if the individual is active or discharged.
       • Discharged clients – forward PHI to Call Center if not attending Walk-In Clinic, Forward document to associated front desk if attending Walk-In Clinic.
       • Non-TCN clients – forward PHI to Call Center if not attending Walk-In Clinic, Forward document to associated front desk if attending Walk-In Clinic.
       • Active clients – determine provider, forward documents to provider to review/sign in DocuSign, upload document into the Electronic Health Record upon completion.
     • Fax non-client related items upon request (i.e., requests for sample medications)
10. Prior Authorization for Medication
    • Prior Authorization for Medication forms are faxed to Medication Company
    • Scan Prior Authorization Form into client Electronic Health record.
11. Forms to be Completed (i.e., Residential Administrators, FMLA, Disability Verification)
    • Obtain form to be completed.
    • Forward form to be completed to treating provider.
    • Log form on Forms to be Completed spreadsheet.
    • Upon completion, mark the form as completed on Forms to be Completed spreadsheet.
    • Follow up with provider if form is not completed and returned timely.
    • Contact client to determine who the form should be sent to upon completion.
    • Review record for Release of Information, complete release of information in-person or via DocuSign.
    • Review form to ensure accurate completion to include but not limited to all portions of the form being completed, signature/title requirements have been met, supervisor signature obtained, if applicable, and date of completion.
    • Upload copy of form into Electronic Health Record
    • Complete Release Invoice/Tracking document
    • Send form to appropriate person/entity by postal mail, fax, secure email, or electronic exchange.
12. Letters
    • Obtain letter from provider.
    • Contact client to determine outcome of letter (letter for client or other entity)
    • Review record to ensure appropriate release of information.
    • Complete and obtain signatures on release of information, if applicable
    • Scan letter to Electronic Health Record
    • Complete Release Invoice/Tracking document
    • Send a letter to an appropriate person/entity by postal mail, fax, secure email, or electronic exchange (portal).
13. Audit (i.e., Change Healthcare, Ciox)
    • Review audit request to determine authenticity.
      • If applicable, obtain audit request from audit portal by logging into portal, navigate to request for records section, print requests.
    • Look up client to determine provider in Electronic Health Record
    • Determine date of records being requested.
    • Match applicable billing codes to records requested.
    • Verify Third Party Payer Consent
      • If there is no Third-Party Payer Consent, notify billing.
      • Add a message board message to obtain a third-party consent at the next appointment.
      • Request consent from auditor.
    • Gather records from Electronic Health Record
    • Complete Release Invoice/Tracking document
    • Send records by postal mail, fax, secure email, or portal upload.
    • Print confirmation of submission, if applicable
    • Upload request for records and confirmation of submission into client Electronic Health Record
      • If applicable, redact other client identifying information from request prior to uploading information electronic health record.
14. Social Security Administration/Opportunities for Ohioans with Disabilities
    • Verify existence of client records
    • Verify validity of release of information
      • If release of information is invalid, upload release of information into electronic portal, define reason for document being invalid, print confirmation page, and upload request, invalid release of information, and confirmation into the client Electronic Health record.
    • Gather records according to request.
    • Upload requests and records to secure portal.
    • Print record upload confirmation sheet.
    • Upload request, release of information, and confirmation to client Electronic Health Record
    • Complete release invoice/tracking document
15. Court Orders (i.e., Drug Court/CASA/Family & Children First)
    • Review Court Order to determine validity and information being requested under the Court Order.
      • If the order is invalid, notify the court and return the order with a request for corrective action.
    • Gather records per court order.
    • Complete Release Invoice/Tracking document
    • Send records.
    • Upload Request for Records and Court Order into Electronic Health record.
16. Referral Follow-Up Letters, Progress Reports
    • Referral Follow Up Letters should be processed within 72 hours of request.
    • Verify release of information
    • Send document to requesting entity.
    • Complete Release Invoice/Tracking
17. Coleman Crisis Prescreen
    • Look up individuals in Carelogic.
    • If an individual is in Carelogic, send documents to provider of record or Julie Wilcox to review/sign in DocuSign.
    • If an individual is not in Carelogic, send the face sheet to support staff to create a shell for the client in Carelogic prior to sending the document to Julie Wilcox to review/sign in Carelogic.
    • Upload the signed document into the client ECR.
18. Probate Court (Statement of Expert Evaluation)
    • Obtain Probate Court forms to be completed from requestor.
      • Depending on the court, the form must be completed by an MD or DO. If the form is completed by an NP, then an MD or DO co-signature is required.
    • Initial probate requests, the original wet signature document must be provided to the court or client to provide to the court.
    • Verify authorization for release of information.
    • Complete release invoice/tracking document
    • Scan completed document into the client ECR.
    • Send document to requestor.
19. Conditional Release Progress Reports (monthly)
    • Obtain conditional release report from case management.
    • Verify completion and accuracy of release of information for Greene County Court and Dr. Marciani at Forensic Psychiatry.
      • If the release of information does not exist, is invalid, or has expired, work with the case manager to obtain a new release of information.
    • Fax conditional release form to Greene County Court, Mental Health, and Recovery Board (or Board authorized to monitor conditional release, and Dr. Marciani at Forensic Psychiatry
    • Complete Release Invoice/Tracking document for all entities who obtain the conditional release form.
    • Scan conditional release form and fax confirmation into the client document library.
20. Jail Inmate Letter
    • Review Authorization for Release of Information for validity.
    • Access Electronic Health Record
    • Complete Inmate Information Request letter
      • Client name
      • Client date of birth
      • Diagnosis
      • Last appointment date/physician name
      • Next appointment date/physician name
      • Medication (medication name, sig, qty, notes, refills, last fill date)
    • Fax letter and release of information to jail
    • Complete release invoice/tracking document
    • Scan authorization for release of information, inmate information request letter, and fax confirmation into client ECR.
21. Women’s Recovery Center (WRC)
    • Access Carelogic Alerts
    • Review Referral form alerts awaiting signature.
    • Review client assessment, ASAM, and authorization for release of information to ensure accuracy of documents and required signatures have been obtained.
      • If documents are not signed, request signatures from required staff by email.
    • Send the most recent Diagnostic Assessment (if DAU completed, send most recent DAU and DA), authorization for release of information, ASAM, Face Sheet, and Insurance Information via email to Women’s Recovery Center
    • Sign referral form to indicate completion.
      • If Assessment, ASAM, Release of Information are not completed, reject the referral form with the rejection reason.
    • Complete Release Invoice/tracking document
22. Revocation of Authorization for Release of Information
    • A client or individual legally authorized to sign may revoke an authorization by providing a written statement or verbal statement to the facility. In the event of a verbal request, the facility will attempt to obtain the revocation in writing following the verbal request for revocation.
    • Staff will complete the Revocation of Authorization for Release of Information form, in Carelogic, as written verification of revocation.
      • Client signatures can be obtained in person, via DocuSign, or via postal mail.
    • Once complete, staff will send a courtesy email to client providers that are involved in the client’s care to let them know the release has been revoked.
    • Staff will print the revoked authorization for release of information along with the signed revocation of authorization for release of information.
    • Stamp the authorization for release of information as revoked with the date of revocation.
    • Scan the revocation and authorization into the document library of the client ECR.
    • Submit a request to #CarelogicIssues to delete the revoked authorization for release of information from the authorization for release of information tab in the client ECR.
23. Sequester client records.
    • Upon request, staff will flag client records as sequestered.
    • Determine those from whom record should be sequestered.
    • Access client ECR Blackbox
    • Enter names of staff who do not have permission to access or enter staff who do.
    • Document on message board message from whom the client record is sequestered.
24. Requests records from outside entities
    • Obtain a signed Authorization for Release of Information for the agency you would like to request records from or verify the existence of a signed Authorization for Release of Information.
    • Creates request for records letter.
    • Sends request for records letter to entity with release of information.
    • Logs request for records onto Request for Records spreadsheet
    • Scans copy of request for records letter into client ECR with fax confirmation sheet if requested by fax.
25. Maintains original documents on record in Xenia Medical Records department (birth certificates/social security cards)
26. Scan and Upload Documents into Electronic Health Record according to the Scanning and Uploading Manual.
    • Create a PDF version of a paper document.
      • Place paper document face up on copier/printer.
      • Press the Scan Button
      • Select the secure folder to scan the document to
      • Press Start
      • The document will be available in the selected secure folder on your computer.
        • Tip: If the document is double-sided, remember to scan both sides of the document by selected 2-sided.
    • Search for the client in the Electronic Health Record
    • Navigate to the Document Library
    • Click Add a Document
      • Non-Service Document
        • Date
        • Document Type
        • Document Name
        • Keywords
        • Add Document
        • Submit
        • Once the document is uploaded, navigate to the document location to ensure the correct document was uploaded.
      • Service Document
        • Date
        • Organization
        • Document
        • Staff
        • Program
        • Signature Date
        • Signing Staff
        • Add Document
        • Submit
        • Once the document is uploaded, navigate to the document location to ensure the correct document was uploaded.
27. Secure Email
    • Staff must utilize secure email when initiating or responding to emails that contain Personal Identifiable Information (PII).
    • Staff must explain secure email to all recipients before using it.
28. Answer incoming phone calls, including but not limited to:
    • Verify caller name, date of birth, and if indicated the last four of social security.
    • Provide assistance with request for records.
    • Aid with completion of release of information.
    • Basic questions regarding records, TCN services provided.
    • Transfer of phone calls to correct department/location.
29. Document contacts in medical records contact document form.
30. Performs routine pulling and re-filing of clinical charts in off-site storage upon request.
31. Maintains organization of off-site storage
    • Periodically review records maintained in storage.
    • Pull records past retention period of 7 years post discharge. Minor records must be maintained for 7 years past the age of majority.
    • Log records to be destroyed into destruction of records database.
    • Destroy records according to agency standards.
32. Logs and destroys records which exceed retention period explained in Policy No.: MR-002.
33. Demonstrates pleasant, professional, and efficient conduct as evidenced by receiving no complaints from callers, co-workers, other agencies, etc. regarding voice tone, accuracy, and responsiveness.
34. Has no unexcused absence from assigned meetings and training.
35. Maintains agency-required annual training including client rights and grievances, safety training, infection control, HIPAA, and others.
36. Remains free from citations by other providers or by consumers from unethical practice and meets standard for profession.
37. Adheres to all organizational and departmental policies, including compliance with all behavioral and ethical expectations.
38. Subpoena
    • Review subpoena for accuracy.
    • Obtain release of information for information to be released, if necessary
    • Determine if subpoena is for a court appearance by provider or for records only.
    • Contact sender of subpoena with any questions pertaining to request or validity of document.
    • If subpoena is for appearance, contact sender to obtain reason for appearance and relay information to staff/supervisor.
    • Obtain records from client Electronic Health Record
    • Complete Certification of Records Letter and obtain notarized signature, if applicable.
    • Complete release invoice/tracking document
    • Scan subpoena and letter.
    • Send records.
39. West Liberty staff perform receptionist duties:
    • Greet all visitors, when office not staffed by support staff, using professional and pleasant conduct.
    • Accepts deliveries from delivery companies when applicable.
    • Assists with Ohio Mobile Shred Company and Easton Water delivery.
      • All invoices are immediately sent to Accounts Payable
    • Distributes incoming mail and packages.
    • Orders office supplies and maintains office supply closet.
    • Coordinate crisis walk-in.
    • Communicates with the Board when necessary, regarding office and/or alarm issues.
40. Referral Contact Information     
    • Monitor Referral Contact Information on TCN Online to ensure accuracy at 100%.
    • Report all discrepancies to supervisor for modification.
    • Provide new referral sources to supervisor.
41. Meet Client Care Hour Expectations:
    • Staff will have no more than five (5) scanning errors per quarter (exclude items identified immediately
    • 100% compliance with HIPAA/42 CFR Part 2
    • Staff will process all requests for records within 25 days of the request being received.
    • No more than one scheduled day off and no more than two missed timecard punches or errors during the quarter.
    • No substantiated client/coworker complaints.
42. Other job duties as assigned.
43. Demonstrates and supports the company core values TCN C.A.R.E.S. “Commitment, Accountability, Respect, Empathy, Service”
44. Adheres to all organizational and departmental policies, complying with all behavioral and ethical expectations.
45. Completes all agency-required trainings

 Minimum Qualifications:

• Education: High School Diploma or equivalent
• Certification:
• Other: Minimum of one year experience working in the medical record field and/or behavioral health field preferred. Computer experience required.

Knowledge, Skills, & Abilities:

Knowledge of:

• State and Federal laws
• Health Insurance Portability and Accountability Act (HIPAA)
• Code of Federal Regulations (42 CFR Part 2)
• Safety rules and procedures
• Agency policies and procedures
• Computer and software systems.
• Word, Excel, and Microsoft Office
• Fax Systems

Skills:

• Capacity to perform duties effectively under potential emotional stress and conflict situations.
• Proficiency in utilizing basic computer skills and office equipment for documentation and communication purposes.
• Practice of a client-focused approach, demonstrating active listening skills, reading comprehension, critical thinking, and leadership abilities.
• Maintains current knowledge of applicable federal and state privacy laws (HIPAA & 42 CFR Part 2)
• Name and number recognition.
• Multi-Task

Abilities:

• Willingness and physical capability to engage in activities are essential to meet the fundamental needs of the position. This includes occasional lifting up to thirty (30) pounds.
• Use of computer keyboard
• Use of telephone
• Standing and sitting for periods of time, bending, stooping.
• Ability to see, hear, and communicate information clearly.

Salary : $16 - $19