Medical Records Technician

MEDICAL RECORDS TECHNICIAN

JOB DESCRIPTION:   The Medical Records Technician coordinates the maintenance of medical record files (acute, residential, and outpatient), provides telephone and reception coverage for the Health Information Services (HIS) Department, coordinates processing of discharge and active charts, maintains accurate computerized databases, medical transcription and decrypting, processes daily census reports, handles Release of Information (ROI)  requests, and other duties to assist in the efficient functioning of the HIS Department.

JOB RESPONSIBLITIES:      

1. Abides by the system’s policies and procedures, State and Federal regulations, and HIPAA guidelines while processing patient’s ROI requests.
2. Enters and maintains computerized deficiency system and prints weekly reports; analyzes each record, tags and untags deficiencies.
3. Assembles charges upon discharge for retrospective and discharge processing; copies records for Retro-Insurance Reviews.
4. Analyzes each discharged record, tags and untags deficiencies ensuring compliance with all applicable policies.
5. Assists in verification of billing ICD-10 codes as needed.
6. Retrieves records for direct caregivers to complete or review; purges records as necessary.
7. Prints records from microfilm
8. Ensures records are filed in appropriate slots/order.
9. Decrypts, corrects, and prints transcribed reports, tags reports with appropriate physician’s tag, and places in appropriate medical record.
10. Provides release of information assistance as needed; forwards referral data to next provider; maintains computerized tracking system of all requests processed.
11. Proactively addresses any problems that may jeopardize patient care.
12. Maintains adequate inventory of departmental supplies.
13. Performs other duties as assigned.

EDUCATION/EXPERIENCE:  High School Diploma and Associates Degree or combination of training and experience. One-year experience working in medical records.

KNOWLEDGE/SKILLS:          

• Ability to perform assignments with minimal supervision;
• Ability to work successfully under highly stressful conditions;
• Ability to make sound, independent judgments based on scientific and/or ethical principles;
• Capability of adapting to varying workloads and work assignments on a constant basis;
• Effective comprehensive reading skills, strong communication skills, written and verbal.
• Must have a working knowledge of computers.

MINIMUM REQUIREMENTS OF THE POSITON:

• Must be able to complete new hire requirements such as State of Alaska Background Check and Drug Testing.
• Must be able to demonstrate special training, knowledge and skills specific to job and/or program competency within the first three (3) months of training.
• Must complete all mandatory in-services annually.
• Must be tested for Tuberculosis with a PPD skin test or chest x-ray upon hire; PPD skin test required annually or chest x-ray annually thereafter.

GENERAL WORKING ENVIRONMENT:  Working conditions for all employees are as follows, but not limited to a psychiatric hospital setting; some risk involved in the event of aggressive patient(s); work load may include day, evening, night, weekend and/or holiday shifts.  Employees occasionally exposed to blood borne pathogens, and loud noise levels. 

Mental demands described herein are representative of those which must be met by an employee to successfully perform the essential functions of the job, but are not limited to the ability to remain calm in a stressful environment; and the emotional stability, physical stamina and agility to handle stress and respond quickly and effectively to emergency situations.

PHYSICAL REQUIREMENTS:  Requirements include, but are not limited to the ability to communicate effectively with employees; the ability to effectively utilize communication equipment; the physical agility to manage cleaning equipment; the ability to read, write.

• Frequently utilize physical ability for standing or sitting for long periods of time.
• Regularly utilize physical ability for speaking, hearing, and seeing with correction for close and distance vision, color discrimination, peripheral vision, depth perception and focusing ability. Speaking and hearing may be necessary for conversing with and assessing employees.
• Able to ascend/descend stairs and ramps; body agility is emphasized.
• Able to bend body downward and forward by bending spine at the waist; bend legs at knee to come to a rest on knee(s)
• Able to extend hands and arms in any direction
• Able to use upper and lower extremities to exert force in a pulling or pushing motion. Exerting up to 50 pounds of force occasionally, and/or up to 20 pounds of force frequently, and/or up to 10 pounds of force constantly to move objects
• Able to raise objects from a lower to higher position or from side-to-side.
• The worker is subject to both environmental conditions: Activities occur inside and outside.
• The worker is subject to hazards: Includes a variety of physical conditions.

• The worker is subject to odors from paint, carpet adhesives, and other construction and cleaning chemicals used for routine maintenance and building renovation.

• Must be able to concentrate amidst distractions; must be able to perform work of a repetitive nature; must respond calmly to potentially volatile clients
• Mental demands include but are not limited to emotional stability, physical stamina and agility to handle stress and respond quickly and effectively to emergency situations.

EQUIPMENT/MATERIALS USED:         Telephone, computer, copier, fax machine, video player small hand tools and writing instruments.