Medical Records Tech 2 _ HRIS

Compile, process, and maintain medical records of hospital and clinic clients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Process, maintain, compile, and report client information for health requirements and standards., * Compiles and maintains clients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts

• Enters data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer
• Identifies, compiles, abstracts and codes client data, using standard classification systems
• Plans, develops, maintains and operates a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information
• Processes client admission and discharge documents
• Protects the security of medical records to ensure that confidentiality is maintained
• Releases information to persons and agencies according to regulations
• Reviews records for completeness, accuracy and compliance with regulations
• Transcribes medical reports.

1. Knowledge of the coding system related psychiatric and medical diagnosis.

2. Knowledge of medical, psychiatric, and anatomical terminology

3. Knowledge of office practices, procedures, and equipment

4. Ability to organize and prepare reports and summaries for oral and written presentation

5. Ability to analyze and evaluate medical records to apply established standards, regulations and laws to specific problems., High School diploma/GED and eligible for certification as a medical records technician by the American Health Information Management Association; or two (2) years of experience in a medical records unit, which involved the independent coding of diagnostic data; or one (1) year of experience required at the lower-level Medical Records Tech 1 (HCT040) or position equivalent.