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)
Responsible and accountable 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.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
§ Prepares charts for new admissions.
§ Closes medical records upon discharge.
· Develops schedule for and conducts audits of the clinical and electronic health records.
· Monitors physician visit schedule.
· Maintains master index system.
· Orders, maintains, and distributes medical records forms.
· Monitors procedures to maintain confidentiality of patient information and guard against loss or destruction of data in accordance with the facility’s policy and procedures.
· Maintains records and completes required forms and documents in accordance with facility policies and state and/or federal regulations.
ENTRY QUALIFICATIONS
· High school diploma or equivalent.
· Working knowledge of medical terminology.
· Proficient in the use of personal computer.
SUPERVISORY RESPONSIBILITIES
Supervises Medical Record assistant, if any, and others for whom they are administratively or professionally responsible.
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