About The Position

Under the general direction of the director (or designee), medical record department, this individual is responsible for processing all internal and external reports needing filing in the records; retrieval of permanent records; file new records and re-file continuing records; any other duties assigned by the Director of Medical Records. Employee works under continual, regular supervision. All work is carried out in accordance with the department’s approved policies and procedures.

Requirements

  • Education: High school graduate or equivalent.
  • Experience: A minimum of two (2) years experienced in HIM/medical records is required.
  • Additional Requirements: Possess basic clerical training, which includes computer skills, basic filing skills and fundamental knowledge of office procedures. Basic knowledge of medical content and sequence. Must be fluent in English, with special emphasis on alphabetization, also able to process work, using both alphabetical and numerical filing systems. The technician must possess relevant experience in clerical duties sufficient for individual development to the level of independent functioning with minimal direction
  • Must have knowledge of medical terminology, and be skilled in the use of DSM and ICD medical terminology.
  • Must be able to perform assignments with minimal supervision;
  • Must be able to perform concentrated and/or complex mental activity with frequent involvement in complex and/or highly technical situations; Must be able to work successfully under highly stressful conditions;
  • Must be able to make sound, independent judgments based on scientific and/or ethical principles;
  • Must be able to comprehend and perform oral and written instructions and procedures;
  • Must be able to collaborate with other multidisciplinary team members in an appropriate fashion;
  • Must be capable of adapting to varying workloads an work assignments on a constant basis;
  • Must have effective comprehensive reading skills, strong communication skills, written and verbal.
  • Must possess a valid California Drivers License in order to drive hospital vehicles or on hospital business.

Responsibilities

  • Abstracts statistical data from discharged patient records using hospital abstracting system.
  • Accurately codes admission, interim and final diagnoses using DSM and ICD coding manuals and their versions.
  • Safeguards and preserves the confidentiality of patient identifiable information in accordance with hospital and departmental policy.
  • Promotes a positive working environment and guest relations.
  • Assumes and/or performs additional duties as requested.
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