Medical Records Technician

About the position

International Health and Medical Services is looking for an experienced Medical Records Technician to accurately manage and maintain patient health records, ensuring that all documentation is complete, organized, and compliant with legal and regulatory requirements. This role involves coding medical information for billing purposes, facilitating access to medical records for healthcare providers, and protecting patient confidentiality.

Responsibilities

• Provide subject matter expertise to leaders and medical center staff.
• Interpret and apply The Joint Commission standards and medico-legal requirements, current federal codes pertinent to medical records, directives and handbooks pertinent to health information management.
• Utilize coding principles and nomenclature and the MS-DRG system; CPT and E&M rules; medical and procedural terminology; anatomy and physiology, regulations governing confidentiality of medical records; release of information laws and statutes; records management; and any policies.
• Provides training for HIM, clinical and administrative staff on HIM topics.
• Performs quality improvement projects regarding HIM issues.
• Assists in preparing various presentations.
• Perform audits and analyses, prepare and present findings and recommendations to the leaders and medical staff.
• Review, analyze and report HIM performance monitors.
• Advises principal investigators and other clinical staff relating to methodologies of retrieving health care data for specific studies.
• Performs data retrieval for special studies as needed.
• Performs quantitative and qualitative reviews of health record documentation to ensure all patient care data entered in the electronic health record (EHR) is accurate, timely, and completed.
• Adheres to established documentation requirements as outlined by The Joint Commission (TJC) regulations and medical-legal requirements.
• Serve as a liaison in the implementation of automated clinical applications pertaining to the EHR.
• Participate in facility committees and subcommittees related to health information and provides technical advice when necessary.
• Participates in training related to VHA Healthcare Information Systems such as VistA, CPRS and other software packages as they relate to HIM job functions.
• Analyze clinical and administrative processes related to information flow.
• Tests and verifies software packages prior to activation in production mode.
• Coordinates with software developers in the local testing of software.

Requirements

• Coding Certification through AHIMA or AAPC -OR- HIM Certification through AHIMA -OR- Health Data Analyst Certification through AHIMA.
• Must be proficient in Microsoft Office: Excel, Word, Power Point, Outlook (email), Windows, Social Media Platforms, and navigating the web.
• Must have excellent oral and written communications skills.
• Must have excellent customer service and self-organization skills.
• Applicants must have the ability to maintain effective working relationships with all levels of employees, both inside and outside the organization.
• Association (AHA) Basic Life Support (BLS).
• Trained in Basic First Aid.
• Employees shall have at least one year of general experience that demonstrates the ability to greet and deal tactfully with the public.
• Capability of understanding and applying written and verbal orders, rules, and regulations.
• All personnel shall be literate and be able to interpret printed rules and regulations, detailed written orders, training instructions and materials, and must be able to compose reports.
• Good judgment, courage, alertness, an even temperament, and render satisfactory performance through knowledge of his/her position responsibilities.
• Ability to maintain poise and self-control during situations that involve mental stress, such as fires, explosions, civil disturbances, and building evacuations.

Nice-to-haves

• Proficiency in Spanish is preferred.

Benefits

• Comprehensive and competitive benefits package including medical, dental, vision, and basic life insurance.
• 401k plan.
• Paid time off.
• Annual bonus.