Job Description
Job Description
Medical Records Technician
Department : Health Information Management Systems (HIMS)
Reports to : Director of HIMS
FLSA Status : Non-Exempt
Type of Position : Full-Time
Revised Date : 09 / 06 / 2022
MISSION & VISION STATEMENT :
The Kewa Pueblo Health Corporation (KPHC) is established for the purposes of carrying out the vision and mission of the Santo Domingo Health Center (SDHC). The MISSION of KPHC is : “ENSURING HEALTH & WELLNESS THROUGH EXCELLENCE IN HEALTHCARE WITH RESPECT FOR CULTURE” and the VISION OF KPHC is : “HEALTHY PEOPLE, HEALTHY COMMUNITY, and HEALTHY LIFESTYLE”.
POSITION PURPOSE :
Responsible for the timely and accurate review and processing of confidential medical records information in accordance with the Privacy Act, Federal and State legal requirements. The incumbent will examine and respond to confidential patient medical records information requests which requires effective time management; multi-tasking; attentional detail; quality focus; documentation; business writing; and database competencies and skills.
PERFOMANCE EXPECTATIONS :
In performance of their respective tasks and duties all employees of the Kewa Pueblo Health Center are expected to conform to the following :
- Uphold all principles of confidentiality and patient care to the fullest extent.
- Adhere to all professional and ethical behavior standards of the healthcare industry.
- Interact in an honest, trustworthy and dependable manner with patients, employees and vendors.
- Possess cultural awareness and sensitivity.
- Maintain a current insurable driver’s license.
- Comply with all Kewa Pueblo Health Corporation and Santo Domingo Health Center policies and procedures, as well
ESSENTIAL DUTIES, FUNCTIONS & RESPONSIBILITIES :
Examines, analyzes, and confidentially processes all time-sensitive correspondence from medical care facilities, insurance companies, employees, social security, legal firms, and other agencies through an electronic fax system in accordance with pertinent laws, policies and procedures such as Privacy Act, Federal and State legal requirements. Reviews each electronic correspondence to ensure accuracy to increase coordination of care; uploads appropriate correspondence for timely completeness in accordance with pertinent laws, policies and procedures.Examines, analyzes and processes time-sensitive, confidential parcel correspondence from medical care facilities, insurance companies, social security, legal firms and other agencies; ensures each parcel correspondence received. Examines, analyzes, and confidentially processes all time-sensitive correspondence from medical care facilities, insurance companies, employees, social security, legal firms, and other agencies through an electronic fax system in accordance with pertinent laws, policies and procedures such as Privacy Act, Federal and State legal requirements. Reviews each electronic correspondence to ensure accuracy to increase coordination of care; uploads appropriate correspondence for timely completeness in accordance with pertinent laws, policies and procedures.Examines, analyzes and processes time-sensitive, confidential parcel correspondence from medical care facilities, insurance companies, social security, legal firms and other agencies; ensures each parcel correspondence received is accurate and follows proper standards in accordance with pertinent laws, policies and procedures such as Privacy Act, Federal and State legal requirements.Examines, analyzes, and processes all release of information (ROI) from medical care facilities, insurance companies, patients, and legal firms to ensure compliance with key elements for completeness of the request. Maintains and updates the RIO log while ensuring accuracy and timeliness of completion and if necessary, reporting.Ensure medical records are uploaded accurately and timely using imaging software; coordinates notifications to appropriate clinical staff for review and signature; ensures all scanned documents are signed in accordance with pertinent policies and procedures.Initiates medical record by searching mater patient index; identifying existing patient records or need to assign a new number; interacting with registration areas and physician offices for information verification; processing or creating the record folder.Prepares all typed material in final form, in accordance with prescribed format, insuring the accuracy of all spelling, punctuation, capitalization, proper sentence structure, grammar, etc.Provides assistance to patients and other clients with preparation of documentation requests, when needed.Researches, reviews, and correlates both old and current medical records to provide a systematic chronological history of medical treatment received by patients from this and other treatment facilities.Files patient reports (i.e., laboratory, x-ray, pathology, operative reports, narrative summaries, consultation reports, etc.,) in a timely manner and in accordance with AAAHC and SDHC Standards that govern Medical Records Department and Policies.Responsible for the accurate and timely archiving of patient medical records and charts for secure and confidential shipments and record keeping to the contractor site for records retention in accordance with pertinent policies and procedures and laws. Maintains the control log; ensure timely requesting of archived medical records and charts for the facility.Ensures that pertinent portion of medical records in response to request for subpoena duces tecum.Performs other duties as assigned.MINIMUM MANDATORY QUALIFICATIONS :
Education :
High School Diploma or GED equivalent.Experience :
Three (3) years Medical Records work experience in a healthcare center or medical facility.Mandatory Knowledge, Skills, Abilities and other Qualifications :
In-depth knowledge and understanding of and sensitivity to the confidentiality and protection under the Privacy Act of 1974, and various SDHC regulations particularly those related the release of information and their application in the organization and total management of health, clinical and medical records.Knowledge of policies and regulations on Tort Claims and Third Party Claims.Knowledge of medical practice and terminology (e.g., anatomy and physiology, prefixes, stems and suffices and standard medical abbreviations) to comprehensively review and analyze routine and non-routine health records to ensure the record is complete as a medico-legal document and complies with Joint Commission on Accreditation of Healthcare Organizations AAAHC and SDHC regulations.Knowledge of quantitative and qualitative analysis of medical records.In-depth knowledge and understanding of and sensitivity to the confidentiality and protection under the Privacy Act of 1974, and various SDHC regulations particularly those related the release of information and their application in the organization and total management of health, clinical and medical records.Knowledge of policies and regulations on Tort Claims and Third Party Claims.Knowledge of medical practice and terminology (e.g., anatomy and physiology, prefixes, stems and suffices and standard medical abbreviations) to comprehensively review and analyze routine and non-routine health records to ensure the record is complete as a medico-legal document and complies with Joint Commission on Accreditation of Healthcare Organizations AAAHC and SDHC regulations.Knowledge of quantitative and qualitative analysis of medical records.Ability to communicate effectively, orally and in writing.Knowledge of grammar, spelling, punctuation and various correspondence formats.Ability to type proficiently and accurately at 45 WPMKnowledge of how to use the Electronic Health Records system.Knowledge of how to use practice management systems.Knowledge and skills to use the computer to retrieve and generate patient record request from EMR / EDR.Working knowledge of computer operating rules and procedures and knowledge of basic computer commands. Keyboard skills and typing proficiency are required.Knowledge and skills necessary to provide patient services to a wide range of age groups (neonate - geriatric). Employee must demonstrate knowledge and ability to perform a variety of clerical procedures and meet the needs of each specific age group.Incumbent may be required to work day, evening or holiday shifts.A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers.PREFERRED QUALIFICATIONS :
Knowledge of RPMS system and NextGen.Prior experience working with Indian Health Services (IHS), a Tribe or Tribal organization.WORK ENVIRONMENT :
The work environment characteristics described here are representative of those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. This position may be exposed to certain health risks that are inherent when working within a health center facility.
PHYSICAL DEMANDS :
The physical demands described here are representative of those that must be met by an employee to successfully perform the primary functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk and hear. There may be prolonged periods of sitting, keyboarding, and reading. The employee must occasionally lift and / or move up to 50 pounds. Specific vision abilities required by this job include reading, distance, computer, and color vision. Talking and hearing are essential to communicate with patients, vendors and staff.
MENTAL DEMANDS :
There are a number of deadlines associated with this position. The employee must also multi-task and interact with a wider variety of people on various and, at times, complicated issues.
OTHER :
All employees must uphold all principles of confidentiality and patient care to the fullest extent. This position has access to sensitive information and a breach of these principles will be grounds for immediate termination.
Disclaimer : The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position. It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed.
