Medical Records 16699

Health Information Management Technician 1 - Medical Records

Duties/Responsibilities:

Organizes, reviews, manages, and analyzes health records for completeness and accuracy to ensure that the maintenance of quality, security, accessibility, and compliance with accreditation and legal requirements in both paper records, hybrid records, and electronic health records.

1. Ensures that the necessary components are present, complete, and accurate, such as clinical progress notes, laboratory reports, and treatment records; and notifies appropriate staff of discrepancies.

2. Collects, reviews, and processes facility staff medical and clinical services documentation as required for Medicaid funding.

3. Transcribes and codes medical, clinical, and mental health services, diseases, procedures, therapy treatments, and diagnoses in accordance with national classification systems.

4. Corresponds with individuals and entities regarding health record information.

5. Enters and maintains databases for the tracking of health information disclosures and runs reports to ensure timely completion of requests.

6. Applies and implements legal and regulatory policies, procedures, and requirements for access and disclosure of Protected Health Information; and tracks, reports, and/or investigates privacy issues and breaches.

7. Provides technical assistance, training, support, and guidance to facility and clinical staff on health information management requirements, including diagnostic and procedural coding, to meet local, State, and federal guidelines.

8. Advises clinical staff on health records policy and procedures and instructs treatment staff in proper methods of entering data into health records.

9. Prepares, retrieves, and participates in data collection and presentation for clinical and administrative review.

10. Conducts audits for utilization review activities; and refers deficiencies to the Utilization Review Committee for further investigation.

11. Implements corrective actions as determined by internal and external audit findings.

Requirements:

Open Competitive: current certification by the American Health Information Management Association (AHIMA) as a Registered Health Information Technician (RHIT).

Please note that the employees would work on holidays only by request of the employer and would only be straight pay. Employees work overtime only at the request of the employer and get paid at overtime rate.