Medical Records Technician

Summary

This position is being re-advertised to solicit additional applications. Applicants who applied previously need not reapply unless submitting updated and/or missing information.
This position is located at Kayenta Service Unit. Division Health Information Management Branch, Medical Records Department, Kayenta Health Center, Kayenta, AZ. This position works in a hybrid (paper/electronic) medical record environment, alternating between abstracting and coding pertinent outpatient medical data.

Duties

Please ensure you answer all questions and follow all instructions carefully. Errors or omissions may impact your rating or result in you losing consideration for the job. This position is located at Kayenta Health Center, HIM Department, Kayenta, AZ. The incumbent: Quantitative Analysis - Performs comprehensive review of the record to assure the presence of all component parts, such as; correct name, health record number, signatures and dates where required, and all reports which appear to be indicated by the treatment rendered. Qualitative Analysis - Evaluates the record for documentation, consistency, accuracy and correlation of recorded data, such as medical necessity and modifier usage. Ensures the final diagnosis as stated by the physician is valid, complete and accurately reflects the care and treatment rendered. Assigns and sequences International Classification of Disease (ICD), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), Current Dental Terminology (CDT), Diagnostic and Statistical Manual of Mental Disorders (DSM) codes to diagnosis and procedures from documented information. Medico-legal Requirements - Makes the final determination that the record is complete, accurate, and reflects data to justify the diagnosis and warrant treatment without infringing on decisions concerning a physician's clinical judgment. Provides ongoing education, updates and briefs physicians, nursing staff, and health care personnel within the immediate organization or work unit, on coding updates, rules, regulations, and guidelines. Generates daily RPMS/EHR reports to review, identifies errors, inconsistencies, discrepancies and/or trends and discusses with the appropriate medical, nursing, or health care providers, and recommends appropriate modifications to RPMS/EHR entry. Assists with performing routine audits in accordance with the facility Compliance Plan and Performance Improvement, which may include findings from provider documentation trends, coding peer reviews, and reimbursement denials.

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