Positions in this job family are responsible for preparing, classifying, and abstracting medical reports in the medical records unit.
Typical duties include:
- Reviewing medical records for completeness and accuracy and referring incomplete or inaccurate reports for correction
- Preparing statistical, case, and other reports
- Preparing materials and forms and gathering information for admissions and discharges
- Ensuring all data is properly coded
- Abstracting charts and patient data to respond to information requests, including determining what materials may be legally released
- Assisting with the development of medical records policies and procedures
- Reviewing policies and procedures for compliance with federal and state laws and agency rules and regulations
- Maintaining the security and confidentiality of patient medical records
- Providing requested information to courts and other judicial inquiries
Requirements & Qualifications
Education and experience
- Eligibility for accreditation with the American Health Information Management Association (AHIMA) 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
Required knowledge and skills
- Knowledge of medical records maintenance methods and techniques
- Knowledge of applicable federal and state laws, agency policies, and facility procedures
- Knowledge of current classification systems and report writing techniques
- Knowledge of medical terminology
- Ability to maintain medical records and code data to records
- Ability to review records for completeness and accuracy
- Ability to prepare reports and abstract information from records and patient data
- Ability to communicate effectively and maintain working relationships
- Ability to use personal computers
Special requirements
- Some agencies may require AHIMA 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 week ago