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Medical Records Technician

External
Full-timeOn-site3mo ago
ComplianceDocumentation
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Responsibilities

  • Create and maintain a separate patient medical record apart from the social record or alien file, using the authorized recordkeeping process.
  • Maintain patient medical records in an electronic health record system and support compliance with required interoperability, access, and reporting standards.
  • Ensure medical records are maintained in a format that is easily accessed and stored in a secure, protected, pest-free, fire-protected, flood-protected, humidity-controlled, and preferably climate-controlled environment.
  • Process medical record requests from authorized health services and authorized government representatives in accordance with contract requirements and applicable privacy and confidentiality laws.
  • Protect patient confidentiality and protected health information in compliance with the Health Insurance Portability and Accountability Act and other applicable federal and state requirements.
  • Support timely retrieval, release, transfer, and secure transmission of patient medical information for authorized care, transport, continuity of care, litigation support, audits, inspections, and other approved purposes.
  • Prepare, assemble, label, and transfer confidential medical records or medical transfer summaries for patient movement between facilities, in accordance with approved procedures.
  • Support health services staff in maintaining documentation for current medications, diagnoses, appointments, consultations, testing status, medical precautions, and equipment needs related to transfer continuity.
  • Maintain accuracy, completeness, and organization of medical documentation and escalate discrepancies, missing information, or record integrity issues for correction.
  • Support daily tracking and documentation of medical requests and appointments within the facility information system as required by contract workflows.
  • Provide records support for requests related to pending or current litigation, congressional inquiries, inspections, audits, complaints, and corrective action activities within required timelines.
  • Maintain records in accordance with applicable National Archives and Records Administration schedules and contract retention requirements; do not destroy or remove records without written authorization.
  • Report any unlawful or accidental removal, defacing, alteration, destruction, or unauthorized access to records immediately upon discovery through established reporting channels.
  • Support remote access, account access coordination, and designated point-of-contact functions for authorized electronic health record data requests, as assigned.
  • Participate in required initial, annual, and recurring training related to privacy, records management, emergency response, safety, and health services operations.
  • Complete initial and annual emergency response training required for facility staff, including cardiopulmonary resuscitation, automated external defibrillator use, emergency first aid, signs of health emergencies, and methods of obtaining emergency medical assistance.
  • Work effectively in a multilingual and multidisciplinary environment while maintaining respectful, professional communication with patients, coworkers, providers, and stakeholders.
  • Use facility office equipment and recordkeeping tools required to scan, store, retrieve, organize, and transmit medical documentation.
  • This list is non-exhaustive, and the role holder may be required to undertake additional duties that are not specifically listed above.
  • Basic Requirements/Certifications:
  • Experience maintaining medical records, health records, or other controlled records in a health care setting.
  • Experience working with an electronic health record system.
  • Knowledge of medical record confidentiality, records retention, and release-of-information requirements.
  • Ability to maintain accurate, complete, and organized records.
  • Ability to protect protected health information and other sensitive information.
  • Ability to support record transfer processes and continuity-of-care documentation.
  • Ability to work with scanning equipment, printers, computers, and electronic record systems.
  • Basic Life Support (BLS) certification.
  • Education Required:
  • High School Diploma or GED equivalent.
  • Attributes and Professional Qualities:
  • Strong oral and written communication skills.
  • Excellent interpersonal skills.
  • Critical thinking skills.
  • Cultural competency.
  • Integrity and honesty.
  • Verbal and written proficiency in Spanish (preferred, not requir

Benefits

Health insuranceDental insuranceRemote work options

Additional Information

This position is contingent on contract award. IHMS USA, Inc. is looking for an experienced Medical Records Technician to create, maintain, secure, retrieve, and transfer separate patient medical records in accordance with contract requirements, records retention rules, privacy laws, and electronic health record standards. The role supports continuity of care by ensuring patient records are complete, accessible to authorized personnel, available for transfer and release workflows, and maintained in a secure environment.


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