Medical Records Technician

Medical Record Technician

The Medical Record Technician is trained to work throughout the record processing section of the department performing customer service duties, Prep/Scan/Index (PSI) of paper medical record documentation, deficiency analysis and birth certificate completion. Based on the job assignment, the technician will be responsible for:

1. Customer Service/PSI (Prep, Scan, and Index): process requests for medical records from walk-ins, fax, and phone requests. Process documents into the document imaging system within 24-48 hours of receipt, selecting the appropriate encounter and document type to ensure easy retrieval.
2. Quantitative analysis of medical records to ensure completeness of documentation as defined in the Medical Staff Rules and Regulations. Associate must identify deficiencies and link the deficiency to the responsible in the Electronic Medical Record (EMR).
3. Birth Certificate completion including paternity acknowledgement and fetal death reports when appropriate. Responsible for entering the legal name of the newborn into the electronic medical record system. Organizes fetal monitor strips for shipment to be digitized.

Associates are expected to assist in the evaluation of methods and participate in problem solving. Provide assistance to customers and hospital personnel. Associate must use a good sense of judgment and display responsibility with minimal supervision. Must organize work and set priorities; work as a team member with peers and other associates; communicate effectively with customers from all levels; withstand stress of a fast-paced environment; handle confidential material; easily adjust to changes in policies, procedures, schedule and fluctuation in workload; understand procedures of all computer applications used in Health Information Department; endure excessive sitting, moderate walking, standing, lifting, have finger dexterity and complete use of hands, arms, and feet. Must work weekends and holidays, as assigned. Performs other duties as assigned by Manager/Director. Must have good vision and good hearing acuity.

Minimum Requirements

• High school graduate or equivalent.

Experience

• Minimum of one year experience in health information department or medical office. In lieu of experience, an Associate Degree in HIM.
• Electronic health record processing experience

License/Registration/Certifications

• Must be eligible to obtain and retain South Carolina Notary Status

Preferred Requirements

Preferred Education

• Associates Degree HIM

Preferred Experience

• Working knowledge of standards and legal requirements for acute care medical records

Preferred License/Registration/Certifications

• RHIT