Basic Purpose
Positions in this job family are assigned responsibilities related to preparing, classifying, and abstracting medical reports in the medical records unit.
Typical Functions
- Reviews medical records for completeness and accuracy and refers incomplete or inaccurate reports to appropriate staff for correction.
- Prepares statistical, case, and other types of reports.
- Prepares materials and forms and gathers all pertinent information and data for admissions and discharges.
- Ensures all data is properly coded.
- Abstracts charts and other patient data in order to respond to requests for information on patients; may make determinations on what materials can legally be released.
- Assists in the development of medical records policies and procedures.
- Reviews existing policies and procedures to ensure they are in compliance with federal and state laws and agency rules, regulations, and policies.
- Insures the security and confidentiality of patient medical records.
- May supply requested information to courts and other judicial inquiries.
Level Descriptor
This is the career level where incumbents prepare, classify, and abstract medical records, performing assigned duties at the full performance level.
Additional Job Details
- Agency: Department of Corrections
- Supervisory Organization: DOC Medical/GPCC
- Worksite: Great Plains Correctional Center/Medical
Requirements & Qualifications
Qualifications
- Eligibility for accreditation with the American Health Information Management Association as a Registered Health Information Technician (RHIT), or
- Two years of experience working with patient records in a medical setting such as a hospital, state institution, medical clinic, or physician's office.
Knowledge, Skills, and Abilities
- Knowledge of medical records maintenance methods and techniques.
- Knowledge of applicable federal and state laws and agency/facility policies and procedures.
- Knowledge of current classification systems, report writing techniques, and medical terminology.
- Ability to maintain medical records, code data to records, review records for completeness and accuracy, prepare reports, abstract information, present information effectively, and maintain effective working relationships.
- Ability to use personal computers.
Special Requirements
- Some agencies may require accreditation as an RHIT.
- Some agencies may require eligibility for registration as a Registered Health Information Administrator (RHIA).
Location
Oklahoma, US
Employment Type
Full-time
Experience Level
Associate
Salary Range
$36,935 - $36,935
Remote work allowed
No
Posted
1 month ago