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SalaryThis position performs medical record technician and coding duties in support of the Spirit Lake Health Center (SLHC) Health Information Management Department. Work is performed and duties are carried out in accordance with established policies, procedures, and SLHC core values.
Major Duties & Responsibilities
• Ensures that confidentiality of patient health records is maintained at all times.
• Analyzes, abstracts, data enters various parts of the electronic health record and codes all necessary information from the dental records (Dentrix) from the coding queue.
• Analyzes and abstracts all necessary information from the electronic health record to reflect secondary complications and co-morbid conditions.
• Codes diagnosis and/or procedures from the electronic Medical Records, and assures the final diagnosis and procedures as stated by the medical provider are valid and complete.
• Codes complex and difficult records accurately; makes complete and accurate selection of the principal diagnosis and principal procedure/operation; diagnosis codes are sequenced properly; and assures that all orders (medication, lab, and radiology) have been documented properly to support level of services and reflect the medical necessity for the order.
• Assures the presence of all component parts of the electronic health record, including correct identification, health record number, signatures, dates, accurate and complete notes (chief complaint, history of present illness (HPI), review of systems, examination, and assessment and plan are completely documented.
• Examines the level of services to ensure it is accurate and appropriate for the documentation in the note.
• Completes medical record by reviewing information; notifying health care providers of record deficiencies; tracking outstanding records; and resolves medical record discrepancies by collecting and analyzing information.
• Performs data entry of medical information.
• Provides education and coding updates to the medical staff, business office staff, and other health care providers regarding changes to rules, regulations, and guidelines.
• Provides medical record information by answering questions and requests of patients, hospital staff, law firms, insurance companies and government agencies. Assists with releases of information, on an as need basis and enters the specific information into the Release of Information Package.
• Performs scanning of outside records, consents, physicals, releases of information, etc.
• Responsible for answering phones and assist patients, co-workers, etc., with any questions and/or concerns they may have.
• Must comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPAA).
• Performs related duties.
Knowledge Required at a level appropriate for this position
• Knowledge of Medical Records requirements and functions.
• Knowledge of pharmacy regulations as they pertain to monthly physician order sheets and medication administration records.
• Knowledge of medical terminology, pharmacy terminology, and a practical knowledge of medical procedures and diagnosis.
• Knowledge of the IHS automated Medical Records system.
• Knowledge of computers and job-related software programs and office equipment.
• Ability to work with personal computer and utilize a variety of software applications.
• Ability to communicate clearly and effectively, both orally and in writing, using tact and sensitivity.
• Ability to work independently.
• Ability to read, write, speak and understand the English language.
• Skill in prioritizing and organizing work.
• Skill in the provision of customer services.
• Skill in the maintenance of electronic health records.
• Skill in the use of such office equipment as a computer, scanner, fax machine, and copier.
• Skill in oral and written communication.
• Skill in interpersonal relations.
• Skill in keyboarding, typing, and data entry.
Supervisory Controls
The supervisor makes specific assignments that are accompanied by clear, detailed, and specific instruction. The supervisor checks completed work for compliance with procedures with instruction, accuracy, adequacy and timeliness.
Guidelines
Guidelines include Health Information Management policies and procedures, HIPAA and other privacy regulation. These guidelines are generally clear and specific, but may require some interpretation in application.
Complexity/Scope of Work
The work consists of related specialized duties. Strict regulations and the need for accuracy contribute to the complexity of the position. The purpose of this position is to perform specialized duties in support of the SLHC's Medical Records functions. Successful performance helps ensure the accuracy of patient Medical Records.
Contacts
Contacts are typically with coworkers, patients, health care providers, and the general public. Contacts are typically to exchange information and provide services.
Physical Demands/Work Environment
The work is typically performed while sitting at a desk or table or while intermittently sitting, standing or stooping. The work is typically performed in an office. While performing the duties of this Job, the employee is regularly required to sit; use hands and fingers to manipulate, handle, or feel; and, talk or hear. The employee is occasionally required to stand; walk and stoop. The employee must regularly lift light objects. The noise level in the work environment is usually quiet.
Supervisory and Management Responsibility
None
Minimum Qualifications
• High School Diploma/Equivalency and/or 2 year Associate of Applied Science
• One to two (1-2) years of Medical Records coding experience, including extensive experience with electronic health records and data entry in RPMS.
• Must be willing to work towards becoming a certified coder.
• Must successfully pass a criminal and background check.
• Must successfully pass a pre-employment drug screen.
