Medical Records Technician (Health Information Technician)

About This Role

The Medical Records Technician analyzes, processes, and maintains medical records for completeness, consistency, and compliance with various requirements. This role involves correcting deficiencies, performing audits, processing information requests, and coding diagnoses and procedures. It also includes establishing and monitoring medical records for admissions and transfers within a correctional institution setting.

Responsibilities

• Analyze medical records for completeness, consistency, and compliance with Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Bureau of Prisons, and medical staff requirements
• Take measures to correct deficiencies by notifying the appropriate person
• Perform monthly medical record audits in coordination with medical staff
• Process requests for medical information from outside hospitals, clinics, and physicians
• Coordinate notification of transfers to other health services departments
• Code complicated diagnoses and procedures for discharged inmates using ICD-9-CM
• Ensure diagnoses and procedures are supported in the medical record and appropriately reported via Sentry
• Establish medical records for all new admissions to the facility
• Acquire, monitor, and account for medical records accompanying patients transferred from other BOP institutions
• Maintain security of the institution, preceding all other responsibilities

Requirements

• All academic degrees and coursework must be completed at a college or university that has obtained accreditation or pre-accreditation status from an accrediting body recognized by the U.S. Department of Education

GL-06:

• At least one year of specialized experience equivalent in difficulty and complexity to the next lower grade level in federal service
• Familiarity with various automated and data systems
• Ability to key and/or code information
• Experience demonstrating technical and administrative support through the ability to review, analyze, code, compile, and extract records data
• Experience in organizing and checking medical records for completeness, accuracy, and compliance with regulatory requirements
• Experience in maintaining tracking and suspense systems
• Experience requiring the coordination and scheduling of appointments to facilitate patient treatment
• Experience in performing a variety of administrative duties such as preparing reports, purchase orders, receiving reports, pay vouchers, and medical referrals for treatment

GL-07:

• At least one year of specialized experience equivalent in difficulty and complexity to the next lower grade level in federal service