Medical Records Technician - Wilmington, United States - Department Of Veterans Affairs

Description

Summary

The Wilmington VA Medical Center is recruiting for a Medical Records Technician - Health Information Technician (HIT). The Medical Records Technician - Health Information Technician will function in Health Administration Service.

Duties

Duties of a Medical Records (HIT) Technician includes, but not limited to:

• Adheres to established documentation requirements as outlined by The Joint Commission regulations, Veterans Health Administration (VHA) guidelines, as well as medical-legal requirements.
• Reviews records for adherence with CMS guidelines related to student, resident supervision and attending physician presence and documentation.
• Compiles reports to insure provider specific and service compliance.
• Maintains a control system to ensure completion of all inpatient and outpatient records in accordance with VA, The Joint Commission, CMS and other regulatory agencies standards.
• Reviews health records to ensure that all records contain sufficient information to meet medical/legal requirements, to ensure continuity of patient care, and to support education and research needs.
• Assists clinicians with completion of delinquent/incomplete health records.
• Consults with the appropriate clinician(s) for clarification when conflicting or ambiguous information appears in the health record documentation.