Medical Records Technician
4 weeks ago
This position is located in the Health Information Management (HIM) section at the Roseburg VA Healthcare System (RVAHCS). MRTs HIT perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRTs HIT check for accuracy, completeness, and timeliness of the health record and monitor and report for regulatory compliance.
Duties
This is considered the journey level for MRTs HIT.
MRTs HIT at this level review, analyze, abstract, maintain, extract, and compile information from the health record independently with minimal supervision.
They analyze health records for accuracy, completeness, timeliness, consistency, and compliance ( e.g., scanned, uploaded, use of correct titles, linked to correct encounters, etc.) with HIM industry standards, policies, procedures, laws, regulations, and accreditation requirements.
They also coordinate and/or perform health record review activities to satisfy external accreditation requirements and medical center performance measures.They communicate regularly with staff at various levels of the organization regarding delinquent health records, and notify individual clinical providers regarding incomplete medical records.
MRTs HIT prepare complex reports, calculate department statistics, note the status of all incomplete/delinquent records, and submit reports to the appropriate administrative and clinical staff and committees/leadership to ensure deficiencies are resolved and completed appropriately.
They serve as the expert resource for clinical staff and assist clinical providers with completion or correction of their health record documentation.
They conduct the review of incomplete records for individuals clearing the facility.MRTs HIT coordinate the use of medical speech recognition/transcription and monitor, verify, troubleshoot, correct, and/or upload all transcription/medical speech recognition to maintain completeness and accuracy of health records.
They serve as the technical expert in health record content and documentation requirements.
The Roseburg VA Healthcare System consists of one Veterans Health Administration (VHA) facility located in Roseburg, OR, and three outpatient clinics.
(HUDN ASH), Substance Abuse and Vocational Rehabilitation services. Specialty services include Cardiology, Neurology, Infectious Diseases, Optometry, Ophthalmology, ENT, Endocrinology, Urology, Renal, Gerontology, Pulmonary, Gastroenterology, General Surgery, Dermatology and Vocational Rehabilitation.
Functions:
Incumbent serves as technical expert in health record content and documentation requirements. Incumbent is responsible for performing quantitative and qualitative reviews of health record documentation.
Incumbent is responsible for ensuring that all patient care data entered in the Electronic Health Record (EHR) is accurate, timely, and completed.
Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements.
Reviews records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation. Compiles reports to insure provider specific and service compliance.Maintains a control system to ensure completion of all inpatient and outpatient records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards.
Reviews health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs.
delinquent/incomplete health records.
The incumbent performs the quantitative and qualitative analysis on both electronic and paper-based health records. Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation.
Identifies health record deficiencies, tracks deficiencies and ensures that the appropriate individual completes their deficiencies. The incumbent assists physicians with the completion of delinquent/incomplete health records and serves as the expert resource for clinical staff regarding requirements for complete documentation
Responsible for expediting the completion of the health record when the patient is transferred for care at another medical center, for legal requests, regulatory agencies review, and reimbursement purposes.
Work Schedule:
Monday - Friday
Telework:
Available, Pending supervisor approval
Virtual: This is not a virtual position.
Functional Statement #: 000000
Relocation/Recruitment Incentives:
Not Authorized
Permanent Change of Station (PCS): Not Authorized
Financial Disclosure Report: Not required
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Medical Records Technician
4 weeks ago
Roseburg, United States Department Of Veterans Affairs Full timeSummary This position is located in the Health Information Management (HIM) section at the Roseburg VA Healthcare System (RVAHCS). MRTs HIT perform incomplete health record analysis. They review, analyze, abstract, maintain, extract, and compile information from the health record. MRTs...
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