AIMS -Ahmedabad Institute of Medical Services
Urgently Required
Medical Records Technician / Clerks
Experience : 1 to 5 years
No of vacancies : 1
Job Description: A Medical Record Technician, often synonymous with a Health Information Technician, plays a pivotal role in managing patient health information and medical records in a healthcare setting. These professionals ensure the accuracy, accessibility, confidentiality, and security of both paper files and electronic health records (EHRs). Below is a detailed look into the role, including key responsibilities, qualifications, and essential attributes.
Key Responsibilities: Record Management: Organize, maintain, and evaluate patient records for completeness, accuracy, and compliance with regulations.
Coding and Billing: Assign and verify the coding for diagnoses and procedures using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes, which are crucial for billing and insurance purposes.
Data Entry and Quality Control: Enter, update, and maintain electronic health records (EHRs) and ensure the quality control of collected data.
Confidentiality and Security: Protect patient confidentiality and secure information by following laws and ethics regarding health information.
Compliance: Ensure that health records and health information management practices comply with applicable laws, regulations, and standards.
Interdepartmental Liaison: Work closely with healthcare professionals to clarify diagnoses or to obtain additional information for accurate recordkeeping.
Reporting: Generate and maintain reports on patient data for administrative and legal purposes, including treatment history, diagnostic information, and outcomes.
Education Qualifications: Education: Most positions require at least an associate degree in Health Information Management, Medical Record Technology, or a related field. Some roles may prefer a bachelor’s degree.
Certification: Many employers require certification, such as the Registered Health Information Technician (RHIT) or Certified Tumor Registrar (CTR), depending on the area of specialization. Certification usually requires passing an exam and maintaining professional competence through continuing education.
Technical Skills: Proficiency in medical software, EHR systems, and basic understanding of medical terminologies, coding, and billing processes.
Legal and Ethical Knowledge: Understanding of healthcare regulations, including HIPAA (Health Insurance Portability and Accountability Act), and ethics around patient information privacy and security.
Key Attributes: Attention to Detail: Accuracy is crucial in coding medical information and managing records to ensure proper care, billing, and compliance.
Analytical Skills: Ability to interpret medical records and abstract data effectively.
Integrity: Strong ethical standards to handle confidential information responsibly.
Communication Skills: Effective communication with healthcare professionals to gather additional information or clarify documentation when necessary.
Organizational Skills: Ability to manage time efficiently, prioritize tasks, and maintain organized records in a fast-paced environment.
About the Role: The role of a Medical Record Technician is integral to the healthcare industry’s operational and financial efficiency. It bridges clinical operations with billing and compliance, ensuring that patient care is accurately documented and financially accounted for. With the healthcare industry increasingly relying on electronic health records, the demand for skilled technicians in this field is growing. This role not only offers a pathway into the healthcare sector for those interested in information management and technology but also plays a critical part in improving patient care and health outcomes through effective management of medical information.