Medical Records Transcriptionist jobs in Nebraska

Non-Exempt, FT Position, Monday - Friday, 40 hours per week

General Summary:

Assigns ICD-10 CM diagnosis and procedure codes to patient records and forwards reports as requested. Compile, process, and maintain medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Process, maintain, compile, and report patient information for health requirements and standards in a manner consistent with the healthcare industry's numerical coding system.

Essential Functions:

• Attention to Detail – job requires being careful about detail and thorough in completing work tasks.
  • Ensures coding of all diagnoses/procedures is in accordance with ICD-9/ICD-10 CM coding principles and the Coding Manual.
  • Is knowledgeable of all charting and coding requirements, including pediatric and SNF.
  • Compile and maintain patient’s medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts.
  • Consult classification manuals to locate information about disease processes.
  • Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures, or treatment into computer.
  • Identify, compile, abstract, and code patient data, using standard classifications systems.
  • Prepare statistical reports, narrative reports, or graphic presentations of information, such as birth registry data for use by hospital staff, researchers, or other users.
  • Process and prepare business or government forms.
  • Process patient admission or discharge documents.
  • Resolve or clarify codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team’s regular meetings.
  • Review records for completeness, accuracy, and compliance with regulations.
  • Inserts any missing patient information on transcribed report, if necessary.
  • Tags blank signature lines for provider signatures and routes documents to providers.
  • Analyzes medical records of discharged patients for completeness and accuracy according to department and hospital policy and procedures.
• Dependability – job requires being reliable, responsible, and dependable, and fulfilling obligations.
  • Regular and reliable attendance.
  • Process and prepare business or government forms and transcribe documents.
  • Release information to persons or agencies according to regulations.
  • Downloading transcribed reports and saving file in appropriate location.
  • Retrieves transcribed reports from printer after transmitted from the transcription service.
  • Inserts any missing patient information on transcribed report, if necessary.
  • Collects all discharged patient medical records from the patient care units on a daily basis.
  • Collects loose filing for those discharged medical records and scans into chart.
• Cooperation – Job requires being pleasant with others on the job and displaying a good-natured, cooperative attitude.
  • Retrieve patient medical records for physicians, technicians, or other medical personnel.
  • Assists transcription service with any information needed (i.e., daily census).
  • Deals with a wide variety of personalities in a professional and tactful manner.
  • Communicates regularly with the HIM Director regarding any problems, issues or concerns in his/her sections.
  • Assists in answering the telephones and taking accurate messages.
  • Pulls requested medical records within time specified.
  • Maintains a good working relationship within the department and other departments.
• Integrity – Job requires being honest and ethical.
  • Protects the confidentiality of patient information, as well as access to computer files and access codes.
  • Supports and maintains a culture of safety and quality.
• Independence — Job requires developing one's own ways of doing things, guiding oneself with little or no supervision, and depending on oneself to get things done.
  • Prepares medical records for scanning.
  • Scans and indexes health and administrative information into the hospital’s electronic health record system.
  • After all information is scanned and indexed, files or destroys the paper files, per policy and procedure.
  • Scans and indexes loose medical record documents received daily.
  • Completes scanning and indexing within established timeframes.
• Compliance:
  • Promotes and adheres to the provisions of the compliance program.
  • Communicates the mission, ethics and goals of the facility.
  • Complies with all organizational policies regarding ethical business practices.
  • Promotes and adheres to the TVHS core values and Standards of Behavior.

Education and Experience:

• RHIT, CPC or CCS certification preferred
• 1-2 years previous years of experience preferred
• Previous experience or education in coding required
• Knowledge of CMS and state charting requirements required