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Health Information Technician

Position Title: Medical Records/Health Information Technician

Reports To: Medical Records, Health Information, or Clinical Services Manager

Job Summary: This position is responsible for assembling patient information into patients’ medical charts/records in accurate and complete manner. 

Essential Functions:
  1. Assembles patients’ health information including patient symptoms and medical history, exam results, X-ray reports, lab tests, diagnoses, and treatment plans. 
  2. Reviews to ensure all forms are completed, properly identified, and signed and that all necessary information is in the manual and/or computer file in preferred style such as chronological. 
  3. Communicates as needed with physicians and other health care professionals to clarify diagnoses or obtain additional information.
  4. Submits files/documentation to physicians and other clinicians as requested for review, quality assurance checks, and other purposes.
  5. Provides charts/documents requested for use in legal actions, following patient consent/confidentiality protocols.
  6. Codes patients’ information periodically (as back-up) for insurance purposes. Assigns a code to each diagnosis and procedure (diagnosis-related group [DRG]).
  7. Uses practice management software to store, tabulate, analyze and retrieve data to improve patient care, control costs, respond to surveys, or use in research studies.
  8. Protects patients’ health information for confidentiality, authorized access for treatment and data security.
  9. Performs other duties as assigned.
‚ÄčSupervises:  This position has no supervisory responsibilities. 

Education: High school diploma. Associate’s degree from a community/junior college preferred. 

Experience: Minimum two years of medical records clerk/health information technician experience, preferably in medical practice setting.

Other Requirements: Registered health information technician (RHIT) designation preferred (offered by the American Health Information Management Association.) 

Special Characteristics:  
  1. Knowledge of biology, chemistry, health, and computer science.
  2. Knowledge of medical terminology and coding such as CPT and ICD codes.
  3. Knowledge of legal and ethical considerations related to patient information.
  1. Skill in putting information in preferred medical record system, meeting clinic standards.
  2. Skill in dealing with masses of information in organized manner.
  1. Ability to alphabetize and put information (materials, forms, etc.) into chronological order.
  2. Ability to analyze medical records for completeness and accuracy, paying attention to detail.
  3. Ability to schedule time and assignments effectively.
  4. Ability to competently use Microsoft Office and appropriate practice management software.
Equipment Operated: Range of medical records equipment and supplies, including computer hardware/software, manual files, and sorters.

Physical and Mental Demands:
  1. Must possess the physical and mental abilities to perform the tasks normally associated with a Medical Records Health Information Technician that involves standing, sitting, bending, and reaching.
  2. May work at computer monitors for prolonged periods with danger of eye strain and muscle pain.
  3. Could cause stress if workload is heavy.
Other Requirements: 
  1. Registered health information technician (RHIT) designation preferred (offered by the American Health Information Management Association.) 
Disclaimer: This description is intended to provide basic guidelines for meeting job requirements.  Responsibilities, knowledge, skills, and working conditions may change as needs evolve.

This material is available to MGMA members only.

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