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)
About the Facility
Blount Memorial Transitional Care Center at Morning View Village is an excellent facility with an inviting culture and a fantastic team. The facility is a 76-bed post-acute care facility that primarily works to rehabilitate short term residents from the hospital.
Medical Records Coordinator Responsibilities:
The primary purpose of your job position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines as well as in accordance with our facility’s established privacy policies and procedures.
· Ensure that active and inactive Point Click Care electronic health records accurately reflect the resident’s condition from admission through discharge.
· Ensure compliance of Point Click Care electronic health records.
· Protect Point Click Care electronic health records from breaches of confidentiality, unauthorized use, theft, and damage.
· Follow audit calendar and communicate closely with the Director of Nursing on audit results.
· Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
· Retrieve resident records (manually/electronically). Deliver as necessary.
· Files information such as nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts
· Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, etc. in accordance with current Privacy Rules.
· Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas as necessary.
· Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
· Assume the administrative authority, responsibility, and accountability of performing the assigned duties of this position.
· Maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information.
Job Type: Full-time
Pay: $15.00 - $20.00 per hour
Expected hours: 40 per week
Benefits:
Schedule:
Experience:
Work Location: In person
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