Health Records Technician

Position Overview

• Review and analyze charts in order to assign appropriate ICD-10-CA/CCI codes to reflect diagnoses, comorbidities, and interventions related to patient's specific encounter and apply appropriate diagnosis typing in accordance with CIHI Coding Standards.
• Abstract coded information into electronic coding program to reflect ICD-10-CA/CCI codes, patient services, physicians, physician service, patient disposition, etc., in accordance with Manitoba Health (MH) and Canadian Institute Health Information (CIHI) standards and guidelines.
• Correct errors received from MH and CIHI and also internal data quality audits.
• Processing of charts in preparation for qualitative analysis, physician deficiency, coding and abstracting.
• Assign physician deficiencies to charts for chart completion.
• Processing of medicolegal correspondence including pulling charts, photocopying, faxing and creating letters for release of information as well as requesting charts from off-site storage.
• Assembly of inpatient/day surgery charts as required.
• Participate in ongoing education and training, including MH and CIHI mandates.

Experience

• Recent two (2) years work experience using ICD-10-CA/CCI coding classification, CIHI Canadian Coding Standards, Discharge Abstract Database (DAD), Manitoba Abstract Data Elements (MADE).

Education (Degree/Diploma/Certificate)

• Graduate of a CHIMA-recognized Health Information Management/Health Record Technician program required.
• Successful challenge of the CHIMA National Certification examination, with a valid CHIMA certificate, current active CHIMA membership preferred.
• Training in regional abstract system.

Certification/Licensure/Registration

• Membership in the Manitoba Health Information Management Association (MHIMA) is preferred.
• Membership in the Canadian Health Information Management Association (CHIMA) is preferred.

Qualifications and Skills

• Excellent communication and interpersonal skills.
• Demonstrated high degree of accuracy and attention to detail.
• Proficient with MS Word, Excel, internet, as well as ICD-10-CA, CCI and Med2020 Abstracting System.
• Knowledge of computerized patient data systems.
• Knowledge of computerized chart tracking/deficiency systems.
• Understanding of terminal digit filing.
• Must be able to work cooperatively and courteously with all staff and physicians.
• Ability to work under pressure to meet deadlines.
• Ability to read, write, speak and understand English.
• Ability to work independently with minimal supervision.
• Ability to manage time effectively and prioritize duties in order to meet deadlines and workload expectations.
• Ability to learn and apply new CIHI standards annually.

Physical Requirements

• Requires high level of attention to detail and accuracy.
• Long periods of sitting using a computer and mouse.