Medical Records Technician

About the Position: This position is located at the 59th Medical Wing - Joint Base San Antonio - Wilford Hall Ambulatory Surgical Center; Lackland Air Force Base, Texas.

This is a Direct Hire Solicitation

Duties

• Analyze medical records retrospectively for adherences to organizational, and Joint Commission (JC) policies.
• File results of various diagnosis tests in patients’ charts for professional staff reference and assures required forms are complete and signed.
• Contact appropriate medical staff regarding questions on the completion of medical records.
• Promote records accountability and ensure all medical records are accounted for via the automated or manual record tracking system.
• Ascertain that all established clinical diagnoses are listed in order of clinical importance in relation to current period of hospitalization and that the terminology is in accordance with accepted nomenclature.
• Ensure initial medical history, progress notes, special tests and records of examinations include sufficient data in support of established diagnosis, surgical, and medical procedures, injuries, etc.
• Organize record in proper sequence, reviews for chronological consistency and ensures correct identification of each record form, signatures, and presence of all reports with appear to be indicated by the nature of each case.

Requirements

• Appointment may be subject to a suitability or fitness determination, as determined by a completed background investigation.
• A Personnel Security Investigation is required.
• Selectees will be required to sign a statement (Condition of Employment) consenting to seasonal influenza vaccinations or must provide a recognized exemption.
• Immunization screening is required. Hepatitis B immunization is required for all positions with direct patient contact. Applicants may be required to show proof of other immunizations depending on the type of position.
• Must be able to obtain and maintain current Basic Life Support (BLS) certification through the American Red Cross or American Heart Association. Advanced certification (e.g., ALS) does not supersede BLS.