Medical Records Technician (Health Information Technician)

Duties

Analyzes medical records for completeness, consistency and compliance with Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Bureau of Prisons (BOP) and medical staff requirements. Performs the monthly medical record audit in coordination with the medical staff. Processes requests for medical information from outside hospitals, clinics, and physicians. Responds to requests from outside sources requesting release of BOP medical information, including court orders, requests by U.S. Attorneys and other institutions. Codes, using ICD-9-CM, complicated diagnoses and procedures for discharged inmates, ensuring diagnoses and procedures are supported in the medical record and appropriately reported via Sentry. Establishes medical records for all new admissions to facility; acquires, monitors and accounts for the medical records which accompany those patients transferred in from other BOP institutions. Performs a full range of administrative duties, including preparing reports, purchase orders, receiving reports, pay vouchers, quarterly and annual reports, medical referrals for treatment to other BOP facilities and pre-certification requests. Along with all other correctional institution employees, incumbent is charged with responsibility for maintaining security of the institution. The staff correctional responsibilities precede all others required by this position and are performed on a regular and recurring basis.