Medical Records Technician abstracts clinical information from medical records and assigns the appropriate ICD or CPT codes using industry-standard coding guidelines. Assigns required DRG (diagnosis-related grouping) codes. Being a Medical Records Technician works with coding databases and software to input and maintain data according to standard procedures. Performs quality audits of work. Additionally, Medical Records Technician maintains and up-to-date knowledge of coding and documentation requirements. Does not require a medical coding certification. Requires a high school diploma. Typically reports to a supervisor or manager. The Medical Records Technician works under the close direction of senior personnel in the functional area. Possesses a moderate understanding of general aspects of the job. May require 0-1 year of general work experience. (Copyright 2024 Salary.com)
Position Summary
Compiles and maintains computerized medical records system related to the patients’ health care delivery system to document customer condition and treatment by performing the following duties.
Essential Duties and Responsibilities
1. Reviews Discharged medical records. Notifies team members and Physicians of incomplete records. Informs CEO timely of non-compliant individuals
2. Medical Records/ Health Information is copied and released in accordance with State and Federal Laws, Policy and Corporate Legal oversight
3. Operates computer to process, store, and retrieve health information
4. Ensure all elements of customer’s medical records received and/or created by the Facility in paper format are converted to digital format in accordance with Birchwood Policy; attach digital format in PPC, as indicated
5. Ensure compliance with Birchwood Policy in obtaining appropriate and timely attending physician signatures on all CMS certification/ re-certification forms
6. Maintain and stock central supply
Competencies
Work Environment
This job operates in a post-acute setting. This role requires regular walking to various locations around the facility.
This role also routinely comes into contact with patients who may have contagious illnesses. Team member is expected to adhere to facility’s no-smoking policy.
Physical Demands
While performing the duties of this job, the employee is regularly required to talk and hear. This position is very active and requires standing, walking, bending, kneeling, and stooping all day. The employee must frequently lift and/or move items over 20 pounds.
Position Type and Expected Hours of Work
This is a position in a post-acute setting that is open 24 hours a day, 365 days a year. Weekend and holiday shifts will be required
Other Duties
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
HIPAA
Team members are required to adhere to policies and procedures implementing HIPAA requirements for the privacy and security of protected health information. Team member are permitted to use and/or disclose only minimum amount of Protected Health Information necessary to complete assigned tasks. Reports all suspected violation of company’s HIPAA policies or procedures to facility CEO.
Knowledge, Skills and Abilities
1. Ability to communicate effectively with internal and external customers at all levels of the organization
2. Proficient computer and Microsoft Application skills. Must have an ability to learn new systems
3. Ability to work with a culturally diverse population
4. Must have positive communication skills and demonstrated adequate maturity and patience
5. Proficient in the English language. Excellent communication (verbal and written), customer service and interpersonal skills
6. Must have excellent organizational skills with attention to detail
7. Must be able to successfully prioritize workload, demonstrate initiative, and analyze situations to make sound decisions
8. Must show initiative and take action on observed needs
Required Education/Experience
Preferred Education/Experience
Job Type: Full-time
Pay: $17.00 - $20.00 per hour
Benefits:
Schedule:
Experience:
Ability to Relocate:
Work Location: In person
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