Medical Records Technician (Health Information Technician)

About This Role

This position is for a Medical Records Technician (Health Information Technician) at the Central Texas Veterans Healthcare System. The role involves reviewing, analyzing, and maintaining health records to ensure accuracy, completeness, and regulatory compliance.

Responsibilities

• Serve as technical expert in health record content and documentation requirements
• Perform quantitative and qualitative reviews of health record documentation to ensure accuracy, timeliness, and completeness in VistA and/or Computerized Patient Record System (CPRS)
• Review records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation
• Review health records to ensure they meet medical/legal requirements, support continuity of patient care, and facilitate education and research needs
• Identify health record deficiencies, track them, and ensure appropriate individuals complete their deficiencies
• Expedite the completion of health records for patient transfers, legal requests, regulatory agency reviews, and reimbursement
• Assess paper health records and electronic CPRS for completeness and note deficiencies
• Track electronic signatures and document deficiencies, communicating them to clinical staff for correction
• Prepare complex weekly and monthly reports on incomplete/delinquent records and compliance, submitting them to administrative and clinical staff
• Perform analytical tasks to resolve "filing" errors on reports uploaded by transcription vendors by correctly identifying and assigning patient reports
• Identify, review, verify, and correct statistical data concerning medical transcription to maintain accuracy of medical and statistical reports
• Review health records for adherence with guidelines related to resident supervision and attending physician presence
• Work with interdisciplinary staff to solve problems regarding proper health record documentation and completion

Requirements

• United States Citizenship
• Proficient in spoken and written English
• Knowledge of medical terminology, anatomy, physiology, and general understanding of health records
• Ability to communicate effectively with internal and external customers
• Ability to utilize health information technology and various office software products (e.g., Microsoft Excel, electronic health records, delinquency tracking software)
• Knowledge of health record documentation guidelines and industry standards
• Ability to manage priorities and coordinate work to complete duties within required timeframes
• Ability to apply knowledge of medical terminology and human anatomy to fully understand the content of a health record

Qualifications

• An associate's degree in health information technology/health information management or a related degree with a minimum of 12 semester hours in health information technology/health information management, or a bachelor's degree in health information management or a related degree with a minimum of 24 semester hours in health information technology/health information management
• One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, and a general understanding of health records

Nice to Have

• 1+ years experience working with medical records
• Organizational skills
• Ability to work under pressure/multitask
• Office management experience
• Telephone Etiquette

Skills

* Required skills

Benefits