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MEDICAL RECORDS TECHNICIAN

Position Description

 

INTRODUCTION:
The purpose of this position is to process medical records in accordance with IHSC procedures and assist the HSA with clinical paperwork.
DUTIES & RESPONSIBILITIES:
1. Maintains the medical records system in accordance with the IHSC policy and procedures.
2. Greets patients, answers telephone, and takes messages as medical facility receptionist as well as maintaining appointment system for patients and clinical staff.
3. Tracks compliance with scheduled patient appointments, making timely reminders notices or calls to the clinical and INS staff prior to each appointment.
4. Determines coding for relevant medical record forms from appropriate references.
5. Files laboratory, radiology and other reports in appropriate sections of the medical record within prescribed time period.
6. Routes clinical reports to appropriate clinic staff within prescribed time period.
7. Archives clinical information from the medical record within prescribed time period in accordance with established policy and procedure.
8. Assures compliance with privacy act and informed consent requirements in all activities.
9. Reviews the records off all detainees scheduled for release to assure compliance with established clinical and record requirements.
10. Writes correspondence for the medical record service and for requests for medical information, enclosing proper authorization and release forms.
11. Reviews all routine forms for completeness, routing incomplete to the appropriate provider for correction.
12. Contacts, as needed, the medical records services of other medical facilities and contract vendors in order to update detainee medical records.
13. Updates, retrieved and transport the medical records to the appropriate provider throughout medical facility.
14. Prepares, updates and maintain a medical record for each patient. Prepares addressograph cards, replacing worn folders, assuring patient name on each folder, etc.
15. Typing or word processing a variety of narrative and tabular material (e.g., correspondence, tabular data, reports, etc.) For the medical records service and the clinical staff.
16. Screening telephone calls and visitors and makes appropriate referrals to other clinic staff and to other organizational segments and makes appointments for the staff.
17. Maintains office files and retrieves files as needed.
18. Maintains clinical data base system using computerized spreadsheet and other programs
19. Monitors and documents hours of all contract health providers in accordance with contract requirements, prepares appropriate reports for HSA.
20. Functions as medical facility epidemiological reporter, contacting, notifying appropriate health authorities of individuals with communicable diseases.
KNOWLEDGE REQUIRED:
1. Thorough understanding of medical terminology and the use of International Clarification of Diseases and Operations to code appropriate forms.
1. Thorough knowledge of the Privacy Act and informed consent requirements.
2. Skill to recognize errors, inconsistencies and omissions in medical records and to work with medical staff to correct information.
3. Working knowledge and familiarity of personal computers and application programs (word processing, data base, spreadsheets).
4. Knowledge of spelling, grammar and punctuation. General knowledge of appointment systems.
5. Familiar with all required guidelines to include the IHSC policies and procedures for medical records, clinical and standard dictionaries and other reference literature.
SUPERVISORY CONTROLS:
May vary by location however administrative oversight is provided by the HSA.
PHYSICAL DEMANDS:
Work is sedentary with some walking, bending, carrying light items and preparing material for shipment/mailing.