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)
Protects the security of medical records to ensure that confidentiality is maintained.
Reviews records for completeness, accuracy and compliance with regulations.
Compiles and maintains patients' medical records to document treatment, physician orders, nursing notes, etc.
Enters data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer.
Plans, develops, maintains, and operates a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.
Identifies and compiles patient data using standard classification systems.
Resolves/clarifies codes and diagnoses with conflicting, missing, or unclear information by consulting with the nursing facility staff or others to get additional information
Purges records as per policy
Orders & receives office supplies and medical forms, journals, books, etc.
Participates in staff meetings and new employee orientation and training programs.
Performs maintenance functions for the department computer system.
Assists in maintaining and fostering customer relationships.
Clear All
0 Medical Records Technician jobs found in New Bedford, MA area