About This Role
This career-level position involves preparing, classifying, and abstracting medical reports within a medical records unit, performing duties at a full performance level. The role focuses on ensuring the completeness, accuracy, security, and confidentiality of patient medical records.
Responsibilities
- Review medical records for completeness and accuracy and refer incomplete or inaccurate reports to appropriate staff for correction
- Prepare statistical, case, and other types of reports
- Prepare materials and forms and gather all pertinent information and data for admissions and discharges
- Ensure all data is properly coded
- Abstract charts and other patient data to respond to requests for information on patients; may make determinations on what materials can legally be released
- Assist in the development of medical records policies and procedures
- Review existing policies and procedures to ensure they are in compliance with federal and state laws and agency rules, regulations, and policies
- Ensure the security and confidentiality of patient medical records
- May supply requested information to courts and other judicial inquiries
Requirements
- Knowledge of methods and techniques of medical records maintenance
- Knowledge of applicable federal and state laws and agency and facility policies and procedures
- Knowledge of current classification systems
- Knowledge of report writing techniques
- Knowledge of medical terminology
- Ability to maintain medical records
- Ability to code data to records
- Ability to review medical records for completeness and accuracy
- Ability to prepare reports
- Ability to abstract information from records and other patient data
- Ability to present information effectively
- Ability to establish and maintain effective working relationships with others
- Ability to utilize personal computers
- Eligibility for accreditation with the American Health Information Management Association 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 a physician’s office
Special Requirements:
- Based upon the duties and responsibilities assigned to the position being filled, a user agency may require accreditation with the American Health Information Management Association as a Registered Health Technician (RHIT); or eligibility for registration as a Registered Health Information Administrator (RHIA)
- Some agencies may have determined positions in this job family to be safety sensitive as defined by 63 O.S. 427.8
Important Details
- Employment type: full-time, regular
- Work location: Mabel Basset Correctional Center/Medical
- This is an on-site position and is not eligible for remote work
About the Company
The Department of Corrections is a state agency responsible for correctional services.
