HEALTH RECORD TECHNICIAN II (SPECIALIST)

Duties

• Perform a variety of complex assigned duties requiring independence of actions and sound decision making.
• Utilizing judgment necessary to evaluate technical abstracting and coding problems, with increased consequences of errors.
• Attend and participate in appointments for Patient Access to Medical Record.
• Photocopy requested records.
• Conduct accurate, structured, concurrent, quantitative audits within the secured treatment area of the facility.
• The ability to physically travel to/from and perform duties on all treatment units in the secured area of the hospital;
• Perform on-unit documentation review, chart maintenance, thinning, and/or filing and maintain chart integrity.
• Analyze in-house requests for patient information and formulate appropriate response.
• Analyze medical records for deficiencies when a patient is discharged or goes to court.
• Communicate incomplete record findings to responsible staff and take steps to have the record completed.
• Assign ICD-10 codes in accordance with ICD-10-CM guidelines.
• Abstract data from a variety of sources.

Qualifications

The Health Record Technician II (Specialist) must possess a minimum of one year of experience performing health record technician duties, including abstracting and coding, and one year of experience performing health information management duties, including auditing and chart maintenance. A Bachelor’s degree in Health Information Management or a related field may substitute for one year of experience. A combination of education and experience may also be considered.