Health Information Technician

Job Description

Job Description

BETHESDA

HEALTH INFORMATION TECHNICIAN

JOB DESCRIPTION

Job Summary : Perform clerical duties. Maintain clinical record systems. Maintain adequate supplies for nursing. Maintain adequate medications, by transcribing resident’s physician orders. Schedule or monitor visits and appointments in accordance with state and federal regulations.

Hours of Work : 8 : 00 a.m. to 4 : 30 p.m. Monday thru Friday. Every 6th Weekend No Holidays

Essential Requirements of Work : (Minimum qualifications necessary to function at full productivity.)

1. Education :

a. Graduate of approved Medical Secretary course or comparable experience or education.

b. Knowledge of nursing home regulations and requirements.

i. Medicare / Medicaid.

i State and Federal regulations.

2. Experience : Previous health related experience desirable.

3. Personal :

a. Genuine interest and willingness to work with ill / infirmed or geriatric aged clients.

b. Arrive to work and depart from work on a timely basis.

c. Highly organized and detail oriented.

d. Appropriate sense, moral integrity.

e. Confidentiality in all matters.

f. Provide pleasant attitude and cheerful disposition towards staff, residents, and family.

4. Knowledge, Skills, and Abilities for Full Performance :

a. Skills in oral and written communication.

b. Proficient in basic communication skills.

i. Must read and understand instructions.

ii. Must write legibly.

iii. Must follow oral directions consistently.

iv. Must be proficient in keyboarding and data entry skills.

c. Must be proficient in ICD-10 coding systems.

d. Must be proficient in understanding and knowledge of medications and medical terminology.

5. Scope of Responsibility :

There will be four full-time medical secretaries. The secretaries will cover for each other in their absence, assuring that the entire facility had medical secretary coverage. The secretaries will work together to process end of month orders and M.D. visit lists. Additionally, the secretaries will assist with the van responsibilities when needed.

Physical Demands of the Job :

1. Prolonged walking and standing.

2. Stooping, bending, and twisting occasionally.

3. Lifting up to 50 pounds occasionally.

4. Prolonged sitting.

5. Pushing / pulling movements occasionally.

Principle Job Responsibilities :

Responsibility : Medical Records

Tasks :

1. Maintain record of physicians’ visits and progress notes in accordance with state and federal regulations.

2. Schedule 30, 60, and 90 day visits as needed.

3. See that all orders required by regulations are received from physicians.

a. Rehabilitation and discharge potential.

b. Level of care - therapeutic Level - PRN.

c. Recreational activities,

d. Standing orders

4. Set up all appointments for eye doctors, dentists, audiologists, speech therapists, etc.

5. See that all charting is complete and signed by physician; progress notes, discharge summaries, lab reports, transfer forms, etc.

6. Insure correct dates are entered on progress notes and orders.

7. Maintain proper chart sequence.

8. Make out exchange forms daily for all appointments; include copy of physicians’ orders and any pertinent information.

9. Make out lab requests and call or fax lab departments with information every week.

a. Make lab requests for lab done here being sent to the hospital or clinic.

10. Transcribe physician’s orders.

11. Process new admissions and re-admits.

12. Process discharges and transfers.

13. Distribute and pick up monthly ADL and mood behavior documentation sheets monthly. File completed documents in permanent charts.

14. Make referrals as necessary under medical assistance.

15. Process hospitalization.

16. Assure that HIPAA regulations are followed. Properly dispose of any non-patient record information that contains P.H.I.

17 Sort and file data returned from clinics and hospitals in proper sequences in charts.

a. Progress notes.

b. Consults, evaluations.

c. Physician’s orders, etc.

• Telephone orders.

a. Send orders to physician for signature and date.

19. Prepare resident’s charts for rounds when physician is due. Set out at each station.

Responsibility : Supplies.

Tasks :

1. Check oxygen tanks, concentrators, and equipment every day.

a. Supply as needed.

2. Check all nursing stations each week and supply all paper materials, pens, pencils, paper clips, etc. Transportation Aide to also assist with stocking supplies.

3. Check for non-working supplies and replace as needed.

4. Order all supplies covered under Medicare Part B.

Responsibility : Computer and Data Entry

Tasks :

1. Enter all new orders and changes daily. Check each unit at least once daily (preferably twice daily) and transcribe new orders.

2. Enter date of physicians visit daily.

3. Enter diagnosis with ICD-10 coding system as needed. Consult R.N. as needed for assistance with ICD-10 codes.

4. Process physician’s orders every other month.

5. Run med sheets every month.

6. Run treatment and nursing task sheets monthly.

7. Update medication sheets, physician’s orders, treatment sheets, and bowel and bladder sheets and behaviors sheets every month before printing for any changes on orders or time codes.

8. Change and add new time codes as needed.

9. Print listings of physician’s schedule every month and mail to physicians.

10. Print listings for other departments as needed.

11. Enter data into nursing task sheets and run every month

Responsibility : Clerical and miscellaneous.

Tasks :