Medical Records Technician

1 month ago


San Simon, United States Tohono O'odham Nation Healthcare Full time
Job DescriptionJob Description

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

Position Summary:

Maintain medical record information in manual and automated record systems. Reviews, analyzes, abstracts, and compiles data; compiles statistics; and performs routine clerical duties supporting the Tohono O'odham Nation Health Care.

Scope of Work: The position is located in the TONHC Hospital and Clinics. The incumbent works under the general supervision of the Medical Records Supervisor.

Essential Duties and Responsibilities:

  • Maintains medical records, creates patient charts and internal identification cards for new patients using unique identification numbers according to established protocols ensures accurate and up-to-date information.
  • Initiates medical records by searching master patient index; identifying existing patient records or assigns a new number; interacts with registration areas and physicians' offices for information verification; processes or creates the record folder.
  • Scans documents, clinical images, clinical tests, and other non-textual data into the patient's electronic medical record.
  • Retrieves patient charts; notes their removal and temporary location, and later re-files them in proper sequence.
  • Prepares chart conversion; consolidates charts, repairs, or establishes new charts as needed.
  • Locates records that have been checked out or are missing.
  • Files documents in the proper patient's record and the appropriate order of assembly received from clinical personnel, including outside providers/facilities.
  • Completes daily chart review to ensure patient records are scanned and filed before the patient's scheduled appointment.
  • Provides necessary forms to patients requesting their medical records; response to questions and patient concerns.
  • Verifies requests, pull, prepares, and copies medical records to be released according to established policy and procedure, legal, and regulatory guidelines.
  • Maintains all medical release forms and enters data into RPMS.
  • Provides medical record information by answering questions and requests of patients, hospital staff, law firms, insurance companies, and government agencies; releases information based on policy and procedures.
  • Schedules and checks patients in and out.
  • Registers and assists patients with setting up their PHR Account.
  • Manages internally and externally generated DICOM and non-DICOM medical images.
  • Reviews, purges, and prepares files for shipment for record retention; updates control logs.
  • Maintains patient confidence and protects hospital operations by keeping information confidential, following release-of-information protocols.
  • Prepares and submits reports.
  • Contributes to a team effort and accomplishes related results as required.
  • Performs other duties as assigned.

Knowledge, Skills, and Abilities:

  • Knowledge of the Tohono O'odham culture, customs, and traditions.
  • Knowledge of applicable federal, state, tribal laws, regulations, and requirements.
  • Knowledge of computer software, including word processing, database, and spreadsheet application.
  • Knowledge of legal regulations and requirements on confidentiality, specifically to the Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996 (HIPAA).
  • Knowledge of medical terminology and usages, covering the full range of general medical, surgical, pharmaceutical, hospital terms, medical abstracts, and abbreviations.
  • Knowledge of the Freedom of Information Act (FROIA).
  • Knowledge of performance improvement activities and tools to participate with the Quality First team in identifying and improving processes.
  • Knowledge of Resource Patient Management Systems (RPMS) and related systems.
  • Knowledge of medical record organization.
  • Skill and commitment to accuracy and detail.
  • Skill in providing superior customer service to external and internal customers.
  • Skill in operating various word-processing, spreadsheets, and database software programs.
  • Skill in organizational and office technology.
  • Ability to retrieve and maintain the terminal digital filing system.
  • Ability to utilize imaging systems.
  • Ability to carry out instructions furnished in verbal or written format.
  • Ability to communicate efficiently and effectively both verbally and in writing.
  • Ability to exercise independent judgment.
  • Ability to handle multiple tasks and meet deadlines.
  • Ability to interact and maintain good working relationships with individuals of varying social and cultural backgrounds.
  • Ability to maintain confidentiality.

Minimum Qualifications:

  • High School Diploma or General Education Diploma, and three years' work experience in medical records management, or an equivalent combination of training, education, and work experience closely related to the maintenance of medical records.

Licenses, Certifications, Special Requirements:

  • Must have completed a Medical Terminology course.
  • RPMS experience preferred.
  • Upon recommendation for hire, a criminal background and a National FBI fingerprint check are required to determine suitability for employment, including a 39-month driving record.
  • May require possessing and maintaining a valid driver's license (no DUIs or major traffic citations within the last three years).
  • If required, must meet the Tohono O'odham Nation tribal employer's insurance requirements to receive a driver's permit to operate program vehicles.
  • Based on the department's needs, incumbents may be required to demonstrate fluency in both the Tohono O'odham language and English as a condition of employment.


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