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)
Under indirect supervision processes inpatient & outpatient admissions and discharges, performs
deficiency analysis on Emergency Room, Ambulance and observation encounters. Performs duties
related to filing the medical record, retrieval and other related health information management
functions as assigned.
Continued employment and raises in this position are dependent upon Central Montana
Medical Center's fiscal viability and:
•
Actions and communications that contribute to a team concept and create a
positive environment for all customers
•
Acceptable performance of essential and all job duties
•
Acceptable attendance record
•
Accountability for safety to self, patients, visitors and all customers, and care of
equipment and building
•
Adherence to departmental and facility policies and procedures, education
requirements, compliance monitoring and reporting, and CMMC Code of
Conduct
•
Accountability for the consequences of own actions
•
Physical and emotional ability to perform essential functions
•
Acceptable background investigation results if required for position
Minimum Education, Experience, Licensure, Certification required:
High School diploma or equivalent
Computer experience, excel proficiency.
Previous hospital experience preferred
ESSENTIAL FUNCTIONS/DUTIES:
(Must be able to perform with or without accommodation)
1 Performs all duties related to the processing of inpatient and outpatient admissions and
discharges
2 Performs deficiency analysis on outpatient diagnostic records.
3 Answers incoming calls an assists ROI.
4 Scans reports into the medical record.
5 Scans inpatient and outpatient medical records into the EHR.
6 Performs all duties related to medical record retrieval
7 Performs HIM duties related to the transfer of patients
8 Performs other duties as assigned
Knowledge, Skills, Abilities:
Knowledge:
Filing systems
Skills:
Computer data entry & proficiency in excel.
Basic Computer skills
Basic typing skills
Phone etiquette
Abilities:
To write neatly and legibly
To operate a calculator with 10 Key proficiency
To read, write, follow directions and perform basic mathematical computations
To perform assigned/routine duties independently and accurately with minimal/reasonable
supervision or assistance
Communicate effectively verbally and in writing
Assume additional duties when requested and to offer assistance to others when indicated
Be willing to attend inservice education programs, workshops, and ask questions to maintain and
improve knowledge level
Utilize references and resources as appropriate to job functions
Type 55 wpm
Remain on task with high volume of disruption.
To multitask
OCCUPATIONAL EPOSURE for this position:
Category I Direct contact with blood or other bodily fluid to which universal
precautions apply
Category II Activity performed without blood/bodily fluids exposure, but
exposure may occur in emergency
Category III Task/activity does not ordinarily entail predictable exposure to
blood/bodily fluids
OTHER EPOSURE for this position:
Radiation
Noise
Other (Specify) Artificial lighting, minimal windows, variation in room
temperature, poor ventilation system.
PHYSICAL DEMANDS:
(Essential functions strength rating for position - see Job Analysis)
Sedentary Exert up to 10# occasionally or negligible force frequently
Light Exert up to 20# occasionally, < 10# frequently or negligible force
constantly Medium Exert up to 50# occasionally, up to 25# or up to 10# constantly
Heavy Exert up to 100# occasionally, up to 50# frequently or up to 20#
constantly
Very Heavy Exert > 100# occasionally, > 50# frequently or
> 20# constantly
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