Medical Records

Summary

The medical records technician is responsible for the overall coordination and supervision of the patients' medical records and the incorporation of clinical documents into those records.

Duties and Responsibilities

1. Processes and maintains medical records of clinic patients in a manner consistent with medical, administrative, ethical, legal and regulatory requirements.
2. Maintains medical records using Electronic Health Records (EHR)
3. Breaks down discharged patients' records to upload them properly into EHR.
4. Properly uploads past medical records.
5. Logs in and out physician orders.
6. Processes and scans patient documents into the EHR
7. Maintains documents in locked cabinets/room to assure confidentiality of patient information.
8. Monitors check in and check out of patient charts by corresponding professional staff.
9. Processes subpoenas and other legal requests.
10. Ensures that all HIPAA standards are in compliance.
11. Performs duties in honest and ethical manner.
12. Performs other duties as assigned.

Qualifications

1. Education/Experience:
2. Must have High school diploma or equivalent.
3. Prior experience in a clinical setting preferred.
4. MS Office programs experience.
5. Experience medical record data entry and document scanning.
6. Experience in release of medical records.

Skills:

1. Use relevant information and individual judgment to determine whether events or processes comply with laws, regulations, or standards.
2. Ability to work independently and to carry out assignments to completion within parameters of instructions given, prescribed routines and standard accepted practices
3. Use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
4. Ability to work with individuals within and outside the organization, in professional and courteous manner.
5. Must develop constructive and cooperative working relationships with others.
6. Understand written sentences and paragraphs in work related documents.
7. Strong ability to use independent judgment and initiative.
8. Organized and able to manage competing priorities.
9. Resourcefulness in problem solving.
10. Actively look for ways to help people.
11. Strong written and verbal communications skills
12. Knowledge of medical terminology
13. Must be extremely detail oriented.
14. Strong organizational and interpersonal skills.
15. Knowledge of EHR
16. Bilingual skills preferred (English/Spanish or English/Creole)
17. Must develop constructive and cooperative working relationships with others.