Medical Records Technician.

JOB SUMMARY:

o The Medical Records Custodian compile, processes, and maintains medical records of hospital; In patient and Out Patient, in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. The custodian is also responsible for maintaining the security, confidentiality, completeness, and accuracy of the medical records.

DUTIES AND RESPONSIBILITIES:

o Organize and manage In-Patients and Out-patient files (IP/OP).
o Making appropriate chronological entries for movements of outgoing and incoming charts.
o Retrieve charts from storage as assigned
o Ensure paperwork is properly filled out.
o Serve as a resource for administrative and clinical offices in regards to medical-legal issues.
o Ensure all files are secure.
o Communicate with physicians and other healthcare professionals to clarify diagnoses or to obtain additional information.
o Maintain electronic health records databases, Electronically record data for collection, storage, analysis, retrieval, and reporting
o Procedure by using classification current ICD- International Classification of Diseases, Revision, and Clinical Modification) and CPT (Current Procedural Terminology) systems software.
o Perform quality assurance checks and auditing the records. Support the MD with all the KPI’s and OPPE data, care pathway compliance and compliance of all the hospital staff with the EMR system and conduct regular audits and submit the report to the medical director.
o Process requests and disclosures of information - internal, external.
o Train all hospital staff in medical records and electronic medical records.
o Compile medical care and census data for statistical reports on diseases treated, surgery performed, and use of hospital beds and graphic presentations of information.
o Review patient records for timeliness, completeness, accuracy, and appropriateness of data
o Organize and maintain data for clinical databases and registries.
o Protect patients’ health information for confidentiality, authorized access for treatment, and data security
o Locate charts and request/provide information when records are not available (Missing charts).
o Maintain confidentiality regarding patient information and regarding administrative matters of a confidential nature.
o Other duties may be assigned as needed by the Line Manager/ Medical Director.

QUALIFICATION, LICENSURE, EDUCATION, EXPERIENCE, SPECIAL SKILLS:

o Diploma/Certification/Graduation in Medical Records in Certificated Institution/ preferred 2 year college education or equivalent.
o Minimum 3 or more years’ of experience in relevant field and/or preferred technical training in healthcare setting.
o Must have advanced computer proficiency, a strong understanding of medical terminology, medical coding and billing and understanding of clinic practice.
o Good English spoken & written, Spanish language advantageous/desirable, but not essential.