Medical Records Technician
- Little or no direct contact with patients
- Translate medical information using code system
- Complete requests for patients' information release
This is one of the few health occupations in which there is little or no direct contact with patients. Medical records and health information technicians (also called billing and coding specialists) assign a code to each diagnosis and procedure. Every time a patient receives health care services, their record is updated with this coded information detailing observations, medical or surgical interventions, and treatments received. The record also includes the results of x-rays and laboratory tests.
Medical Records Technicians also ensure that all medical forms are completed and signed, and that all necessary information is transferred, in coded form, into a computer database, or given to a Medical Transcriptionist to input into a computer record. They regularly communicate with physicians and other healthcare professionals to clarify diagnoses or to obtain additional information. Additionally, coded information is sent to health insurance companies for billing purposes.
Medical records and health information technicians usually work a 40-hour week with some occasional overtime, and experienced technicians who specialize in billing may even work from home. In hospitals, technicians may work day, evening, and night scheduled shifts.
More information can be found via the Additional Information links below.
Requires a degree in:
- AA Degree Medical Records Technology
- Certificate in Medical Records Technology
- Knowledgeable of Federal and State guidelines.
- Conduct clinical chart audits for all active and discharged records as requested
- Assist in annual processing, storage/filling systems of active and discharge records and chart creation/maintenance.
- Assist with special requests for records per research or clinical needs.
- When records supervisor is unavailable, process requests for admission, discharge, and change of information forms for data entry and processing on flow sheets, rolodex, log book, and treatment plan cards.
- Complete data entry case management logs
- Monitor requests for release of information in accordance with company, state and federal guidelines.
- Provide phone coverage and typing for records department as directed by records supervisor.