Senior Medical Records Technician

Job Description - Senior Medical Records Technician (250002K0)

The SR Medical Records Tech will be responsible for reviewing and analyzing inpatient and ambulatory surgery medical records. The role includes reviewing medical records for accuracy of pertinent documents, completeness of the physician signatures and other medical professional data entries. The candidate will collaborate with the Medical Staff Office to report medical record deficiencies and support the medical staff in the completion of the medical record to facilitate medical record availability.

Minimum Education – High School Diploma or GED (Required)

Minimum Work Experience – 2 years experience in processing and/or maintenance of medical records (Required)

Required Skills/Knowledge –

• Strong knowledge of medical record content and identification of documents.
• Reliability, trustworthiness and strict confidentiality of sensitive information.
• Excellent communication skills and problem solving ability.
• Professional presentation at all times.
• Confidence and courtesy when addressing the medical staff.
• Ability to meet quality and quantity productivity standards set by the medical records industry.
• Proficiency in all clerical functions of medical records management.
• Competency in computer skills, operating in a Windows environment such as Microsoft Office and Word.
• All job requirements listed indicate the minimum level of knowledge, skills, and abilities necessary to perform the job proficiently.
• This job description is not to be construed as an exhaustive statement of duties, responsibilities, or requirements.
• Employees will be required to perform any other job‑related instructions given by their supervisor, subject to reasonable accommodation.

• Review discharged patient medical records for completeness and accuracy, based on hospital policy and accreditation and regulatory standards.
• Input incomplete data elements into the delinquency database.
• Facilitate medical record availability for physician completion and retrieve medical records; contact physicians to inform them of the availability of the medical record for review and signature; re‑review the medical record following physician review and signature activity.
• Monitor database to identify physicians with incomplete medical records; draft and send physician an incomplete medical record notification letter.
• File operative reports in the medical record.
• Perform clinical pertinence review of medical records per hospital policy and procedures; prepare medical record deficiency reports as needed by management.

• Collaborate with co‑workers in the completion of daily assignments.
• Contribute to the overall team spirit of the HIM Department.

• Seek educational opportunities related to medical records review and analysis.
• Participate in educational/in‑service offering presented by the Human Resources Department.

• Participate in the CNMC's customer service education program.
• Extend assistance to all customers of the HIM Department.

• Partner in the mission and upholds the core principles of the organization.
• Committed to diversity and recognizes value of cultural ethnic differences.
• Demonstrate personal and professional integrity.
• Maintain confidentiality at all times.

• Contribute to a positive work environment.
• Demonstrate flexibility and willingness to change.
• Identify opportunities to improve clinical and administrative processes.
• Make appropriate decisions, using sound judgment.

• Use resources efficiently.
• Search for less costly ways of doing things.

• Speak up when team members appear to exhibit unsafe behavior or performance.
• Continuously validate and verify information needed for decision making or documentation.
• Stop in the face of uncertainty and take time to resolve the situation.
• Demonstrate accurate, clear and timely verbal and written communication.
• Actively promote safety for patients, families, visitors and co‑workers.
• Attend carefully to important details – practicing Stop, Think,…