Medical Records Technician

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

Position Summary:

Maintain medical record information in manual and automated record systems. Reviews, analyzes, abstracts, and compiles data; compiles statistics; and performs routine clerical duties supporting the Tohono O'odham Nation Health Care.

Scope of Work: The position is located in the TONHC Hospital and Clinics. The incumbent works under the general supervision of the Medical Records Supervisor.

Essential Duties and Responsibilities:

• Maintains medical records, creates patient charts and internal identification cards for new patients using unique identification numbers according to established protocols ensures accurate and up-to-date information.
• Initiates medical records by searching master patient index; identifying existing patient records or assigns a new number; interacts with registration areas and physicians' offices for information verification; processes or creates the record folder.
• Scans documents, clinical images, clinical tests, and other non-textual data into the patient's electronic medical record.
• Retrieves patient charts; notes their removal and temporary location, and later re-files them in proper sequence.
• Prepares chart conversion; consolidates charts, repairs, or establishes new charts as needed.
• Locates records that have been checked out or are missing.
• Files documents in the proper patient's record and the appropriate order of assembly received from clinical personnel, including outside providers/facilities.
• Completes daily chart review to ensure patient records are scanned and filed before the patient's scheduled appointment.
• Provides necessary forms to patients requesting their medical records; response to questions and patient concerns.
• Verifies requests, pull, prepares, and copies medical records to be released according to established policy and procedure, legal, and regulatory guidelines.
• Maintains all medical release forms and enters data into RPMS.
• Provides medical record information by answering questions and requests of patients, hospital staff, law firms, insurance companies, and government agencies; releases information based on policy and procedures.
• Schedules and checks patients in and out.
• Registers and assists patients with setting up their PHR Account.
• Manages internally and externally generated DICOM and non-DICOM medical images.
• Reviews, purges, and prepares files for shipment for record retention; updates control logs.
• Maintains patient confidence and protects hospital operations by keeping information confidential, following release-of-information protocols.
• Prepares and submits reports.
• Contributes to a team effort and accomplishes related results as required.
• Performs other duties as assigned.

Knowledge, Skills, and Abilities:

• Knowledge of the Tohono O'odham culture, customs, and traditions.
• Knowledge of applicable federal, state, tribal laws, regulations, and requirements.
• Knowledge of computer software, including word processing, database, and spreadsheet application.
• Knowledge of legal regulations and requirements on confidentiality, specifically to the Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Knowledge of medical terminology and usages, covering the full range of general medical, surgical, pharmaceutical, hospital terms, medical abstracts, and abbreviations.
• Knowledge of the Freedom of Information Act (FROIA).
• Knowledge of performance improvement activities and tools to participate with the Quality First team in identifying and improving processes.
• Knowledge of Resource Patient Management Systems (RPMS) and related systems.
• Knowledge of medical record organization.
• Skill and commitment to accuracy and detail.
• Skill in providing superior customer service to external and internal customers.