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)
General Purpose: The Medical Records assumes authority, responsibility and accountability for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards and state and federal laws and regulations for long term care facilities. Establishes and implements policies to ensure that records are complete, accurately documented, readily accessible and systematically organized. Collaborates with Administrator and Director of Nursing to allocate department resources in an efficient and economic manner to achieve department objectives.
Education & Qualifications:
1. High school diploma or a GED
2. Licensed by the State of Florida with a current LPN license
3. Experience working in record keeping
4. Must be able to read and write and have the ability to carry out verbal instructions.
5. Computer literate and typing skills.
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