Medical Records Technician (Health Information Technician)

Medical Record Technician Review, analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision. Analyze health records for accuracy, completeness, timeliness, consistency, and compliance with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements. Medical Record Technician duties and responsibilities include but are not limited to: Serves as technical expert in health record content and documentation requirements. Responsible for performing quantitative and qualitative reviews of health record documentation for ongoing regulatory reviews and deficiency analysis. Ensures that all patient care data entered in the electronic health record (EHR) is accurate, timely, and complete. Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations, Veterans Health Administration (VHA) guidelines, as well as medico-legal requirements. Reviews health records for adherence with the Centers for Medicare and Medicaid Services (CMS) guidelines related to student, resident supervision and attending physician presence and documentation. Compiles reports to insure provider specific and service compliance. Maintains a control system to ensure completion of all inpatient and outpatient health records in accordance with VHA, TJC, CMS and other regulatory agencies standards. Reviews health records to ensure that all health records contain sufficient information to meet medico-legal requirements, to ensure continuity of patient care, and to support education and research needs. Notifies clinicians of missing, incomplete, or inaccurate information in their signature blocks (e.g., missing or inaccurate credentials).Assists clinicians with completion of delinquent/incomplete health records. Assesses the health record for completeness, identifies health record deficiencies, tracks deficiencies, and ensures that the appropriate individuals complete their deficiencies. Tracks unsigned/uncosigned notes (e.g., progress notes, operative reports, discharge summaries, etc.) and encounters without associated progress notes, and communicates these deficiencies to clinical staff for completion. Responsible for expediting the completion of the health record when the patient is transferred for care at another medical center, for legal requests, regulatory agencies review, and reimbursement purposes. Performs analytical tasks associated with the resolution of "filing" errors on reports uploaded by a transcription vendor. This includes correctly identifying the patient the report belongs to and filing/assigning it correctly. Identifies any blanks in transcribed documentation and takes appropriate action to track deficiencies, when required by local workflows, and follows up with the responsible provider for correction. Identifies reviews, verifies, and corrects all statistical data concerning medical transcription to maintain accuracy of medical and statistical reports. Compares and resolves discrepancies between reports of admission, discharge, transfers and all outpatient and ambulatory services with contract transcription logs as it relates to timeliness and accuracy of dictated reports completed by medical transcription contractor.

Virtual: This is not a virtual position. Functional Statement #: 32056F, 32055F, 32054F, 32053FRelocation/Recruitment Incentives: Not Authorized Permanent Change of Station (PCS): Not AuthorizedPCS Appraised Value Offer (AVO): Not Authorized