Health Information Technician I

State of Oklahoma

6d•Onsite

About The Position

Basic Purpose: Positions in this job family are assigned responsibilities related to preparing, classifying and abstracting medical reports in the medical records unit. Typical Functions: Reviews medical records for completeness and accuracy and refers incomplete or inaccurate reports to appropriate staff for correction. Collects data and prepares statistical, case and other types of reports. Prepares materials and forms and gathers all pertinent information and data for admissions and discharges. Ensures all data is properly recorded and maintained. Abstracts charts and other patient data in order to respond to requests for information on patients; may make determinations on what materials can legally be released. Reviews existing policies and procedures to ensure they are working in compliance with federal and state laws and agency rules, regulations, and policies. Ensures the security and confidentiality of patient medical records. May supply requested information to the Office of General Council for courts and other judicial inquires. Works with outside providers to schedule offsite appointments and follow-ups to include obtaining necessary medical records and documents. Maintains a schedule of upcoming external appointments and communicates schedule as necessary. May assist in obtaining necessary documentation for Medicaid applications. Completes transfer summaries as appropriate. Gathers medications and pertinent medical records for facility transfers. May assist with ordering and distributing medical supplies. Assists with collecting and providing documentation for internal or external audits. Conducts a medical record audit for incoming and outgoing inmates to ensure a continuity of care. May provide inmate education as appropriate. Opens, scans, reads, and/or distributes communications, including mail, memos, faxes, emails and verbal communications. Level Descriptor: This is the career level where incumbents prepare, classify and abstract medical records, performing assigned duties at the full performance level.

Requirements

Knowledge of methods and techniques of medical records maintenance
Knowledge of applicable federal and state laws and agency and facility policies and procedures
Knowledge of current classification systems
Knowledge of report writing techniques
Knowledge of medical terminology
Ability to maintain medical records
Ability to code data to records
Ability to review medical records for completeness and accuracy
Ability to prepare reports
Ability to abstract information from records and other patient data
Ability to present information effectively
Ability to establish and maintain effective working relationships with others
Ability to utilize computers
Eligibility for accreditation with the American Health Information Management Association as a Registered Health Information Technician; or two years of experience working with patient records in a medical setting such as a hospital, state institution, medical clinic, or a physician’s office

Responsibilities

Reviews medical records for completeness and accuracy and refers incomplete or inaccurate reports to appropriate staff for correction.
Collects data and prepares statistical, case and other types of reports.
Prepares materials and forms and gathers all pertinent information and data for admissions and discharges.
Ensures all data is properly recorded and maintained.
Abstracts charts and other patient data in order to respond to requests for information on patients; may make determinations on what materials can legally be released.
Reviews existing policies and procedures to ensure they are working in compliance with federal and state laws and agency rules, regulations, and policies.
Ensures the security and confidentiality of patient medical records.
May supply requested information to the Office of General Council for courts and other judicial inquires.
Works with outside providers to schedule offsite appointments and follow-ups to include obtaining necessary medical records and documents.
Maintains a schedule of upcoming external appointments and communicates schedule as necessary.
May assist in obtaining necessary documentation for Medicaid applications.
Completes transfer summaries as appropriate.
Gathers medications and pertinent medical records for facility transfers.
May assist with ordering and distributing medical supplies.
Assists with collecting and providing documentation for internal or external audits.
Conducts a medical record audit for incoming and outgoing inmates to ensure a continuity of care.
May provide inmate education as appropriate.
Opens, scans, reads, and/or distributes communications, including mail, memos, faxes, emails and verbal communications.