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Summary Job Description | Tasks | |||
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. | Protect the security of medical records to ensure that confidentiality is maintained. | |||
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Process patient admission and discharge documents. | ||||
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Review records for completeness, accuracy and compliance with regulations. | ||||
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Compile and maintain patients' medical records to document condition and treatment and to provide data for research or cost control and care improvement efforts. | ||||
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Enter data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer. | ||||
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Release information to persons and agencies according to regulations. | ||||
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Plan, develop, maintain and operate a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information. | ||||
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Manage the department and supervise clerical workers, directing and controlling activities of personnel in the medical records department. | ||||
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Transcribe medical reports. | ||||
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Identify, compile, abstract and code patient data, using standard classification systems. | ||||
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Resolve or clarify codes and diagnoses with conflicting, missing, or unclear information by consulting with doctors or others or by participating in the coding team's regular meetings. | ||||
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Train medical records staff. | ||||
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Assign the patient to diagnosis-related groups (DRGs), using appropriate computer software. | ||||
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Post medical insurance billings. | ||||
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Process and prepare business and government forms. | ||||
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Prepare statistical reports, narrative reports and graphic presentations of information such as tumor registry data for use by hospital staff, researchers, or other users. | ||||
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Consult classification manuals to locate information about disease processes. | ||||
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Compile medical care and census data for statistical reports on diseases treated, surgery performed, or use of hospital beds. | ||||
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Develop in-service educational materials. | ||||
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Retrieve patient medical records for physicians, technicians, or other medical personnel. | ||||
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CompGeo Salary Survey Benchmark Job Summary and Competencies
Medical Records Technicians
The Benchmark Job Description below represents the specific Position Characteristics of the job used in the Salary Survey. Benchmark Job Descriptions should be inspected carefully to review the degree of matching between an organizations' Job and the Salary Survey Benchmark. Matching internal Jobs to Salary Survey Benchmark Jobs should not be done on Job Title alone. A thorough comparison of Salary Survey Benchmark to Internal Job Descriptions is recommended. A good overlap should exist on any comparisons used on critical Job Dimensions and Competencies.- Job Description
- Knowledges
- Skills
- Abilites
- Tools and Technology
- Education and Experience
- Alternate Job Titles
- Salaries
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Important Knowledge Competencies | Competency Description | |||
Clerical | Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and other office procedures and terminology. | |||
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English Language | Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar. | |||
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Customer and Personal Service | Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction. | |||
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Computers and Electronics | Knowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming. | |||
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Important Skill Competencies | Competency Description | |||
Reading Comprehension | Understanding written sentences and paragraphs in work related documents. | |||
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Active Listening | Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. | |||
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Speaking | Talking to others to convey information effectively. | |||
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Critical Thinking | Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. | |||
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Monitoring | Monitoring/Assessing performance of yourself, other individuals, or organizations to make improvements or take corrective action. | |||
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Time Management | Managing one's own time and the time of others. | |||
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Writing | Communicating effectively in writing as appropriate for the needs of the audience. | |||
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Social Perceptiveness | Being aware of others' reactions and understanding why they react as they do. | |||
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Service Orientation | Actively looking for ways to help people. | |||
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Coordination | Adjusting actions in relation to others' actions. | |||
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Complex Problem Solving | Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. | |||
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Judgment and Decision Making | Considering the relative costs and benefits of potential actions to choose the most appropriate one. | |||
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Important Ability Competencies | Competency Description | |||
Oral Comprehension | The ability to listen to and understand information and ideas presented through spoken words and sentences. | |||
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Oral Expression | The ability to communicate information and ideas in speaking so others will understand. | |||
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Near Vision | The ability to see details at close range (within a few feet of the observer). | |||
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Speech Recognition | The ability to identify and understand the speech of another person. | |||
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Written Comprehension | The ability to read and understand information and ideas presented in writing. | |||
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Information Ordering | The ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (e.g., patterns of numbers, letters, words, pictures, mathematical operations). | |||
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Category Flexibility | The ability to generate or use different sets of rules for combining or grouping things in different ways. | |||
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Speech Clarity | The ability to speak clearly so others can understand you. | |||
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Written Expression | The ability to communicate information and ideas in writing so others will understand. | |||
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Problem Sensitivity | The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem. | |||
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Deductive Reasoning | The ability to apply general rules to specific problems to produce answers that make sense. | |||
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Finger Dexterity | The ability to make precisely coordinated movements of the fingers of one or both hands to grasp, manipulate, or assemble very small objects. | |||
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Inductive Reasoning | The ability to combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events). | |||
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Selective Attention | The ability to concentrate on a task over a period of time without being distracted. | |||
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Tools/Technology Example | Product Category | |||
Allscripts HealthMatics software | Medical software | |||
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Amazing Charts | Medical software | |||
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American Medical Association CodeManager | Categorization or classification software | |||
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Billing software | Accounting software | |||
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Coding database software | Information retrieval or search software | |||
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ComChart EMR | Medical software | |||
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Computerized indexing systems | Categorization or classification software | |||
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Corel WordPerfect software | Word processing software | |||
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Cyber Records MediChart Express | Voice recognition software | |||
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DRG Grouper software | Categorization or classification software | |||
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Digital Imaging Communications in Medicine DICOM medical imaging software | Medical software | |||
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EAD Systems software | Data base user interface and query software | |||
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EHS CareRevolution | Medical software | |||
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Electronic medical record EMR software | Medical software | |||
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Electronic medical record EMR systems | Medical software | |||
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Email software | Electronic mail software | |||
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Encoder software | Transaction security and virus protection software | |||
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EndoSoft software | Data base user interface and query software | |||
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Entity software | Data base user interface and query software | |||
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Epic software | Medical software | |||
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Fox Meadows Accent Data Manager | Document management software | |||
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Fox Meadows ChartingPlus | Data base user interface and query software | |||
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Fox Meadows EncounterManager | Medical software | |||
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Graphics software | Graphics or photo imaging software | |||
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Greenway Medical Technologies PrimeChart | Medical software | |||
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HealthProbe software | Medical software | |||
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Holt Systems eMedRec | Medical software | |||
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Hyland Software OnBase | Document management software | |||
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IBM Lotus 1-2-3 | Spreadsheet software | |||
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IDX Systems IDXtend | Medical software | |||
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IDX Systems Patient Chart Tracking | Document management software | |||
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Information Resource Products Clinical Coding Expert | Expert system software | |||
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Laserfiche software | Document management software | |||
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LeonardoMD Renaissance software | Medical software | |||
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Logician software | Medical software | |||
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MD Synergy Medical Appointment Scheduling | Calendar and scheduling software | |||
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MedStar Systems DrWorks | Medical software | |||
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Mediasoft mediOFFICE | Medical software | |||
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MedicWare software | Medical software | |||
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Microsoft Access | Data base user interface and query software | |||
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Microsoft Excel | Spreadsheet software | |||
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Microsoft Office software | Office suite software | |||
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Microsoft Word | Word processing software | |||
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NCG Medical Systems d-Chart | Medical software | |||
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NDCMedisoft software | Accounting software | |||
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NextGen Healthcare Information Systems EMR | Medical software | |||
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O-HEAP software | Data base user interface and query software | |||
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PowerMed software | Medical software | |||
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Practice Partner Patient Records | Medical software | |||
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Practice Partner software | Medical software | |||
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Presentation software | Presentation software | |||
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Purkinje Dossier | Data base user interface and query software | |||
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QMSoftware Receivables Management | Accounting software | |||
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SOAPware software | Medical software | |||
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STAT! Systems QD Clinical | Medical software | |||
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ScanSoft Naturally Speaking | Voice recognition software | |||
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Scantron imaging software | Optical character reader OCR or scanning software | |||
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Scheduling software | Calendar and scheduling software | |||
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Siemens Soarian Financials | Accounting software | |||
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Siemens Soarian Scheduling | Calendar and scheduling software | |||
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SoftMed ChartLocater | Document management software | |||
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SoftMed ChartRelease | Data base reporting software | |||
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SoftMed ChartReserve | Document management software | |||
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Speech recognition software | Voice recognition software | |||
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SynaMed EMR | Medical software | |||
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VantageMed ChartKeeper | Medical software | |||
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VersaForm software | Medical software | |||
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Visionary Medical Systems Visionary OFFICE PM | Medical software | |||
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Voice dictation software | Voice recognition software | |||
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Web browser software | Internet browser software | |||
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Welford Chart Notes | Medical software | |||
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Word processing software | Word processing software | |||
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e-MDs topsChart | Medical software | |||
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eClinicalWorks software | Medical software | |||
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10-key calculators | Calculators or accessories | |||
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Barcode attachment equipment | Medical charting systems components or accessories | |||
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Barcode readers | Bar code reader equipment | |||
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Credit card machines | Electronic funds transfer point of sale equipment | |||
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Desktop computers | Desktop computers | |||
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Dictaphones | Dictation machines | |||
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Encoders | Encoder decoder equipment | |||
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Fax machines | Facsimile machines | |||
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Flat-top scanners | Scanners | |||
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Label printers | Compact disc CD or labeling printers | |||
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Laser printers | Laser printers | |||
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Light pens | Light stylus | |||
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Microfiche viewing machines | Microfiche or microfilm viewer components or accessories | |||
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Microfilm viewing machines | Microfiche or microfilm viewer components or accessories | |||
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Multi-line telephone systems | Special purpose telephones | |||
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Notebook computers | Notebook computers | |||
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Optical readers and writers | Optical character recognition systems | |||
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Paper shredders | Paper shredding machines or accessories | |||
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Personal computers | Personal computers | |||
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Postal scales | Postal scales | |||
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Scanners | Scanners | |||
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Switchboards | Premise branch exchange PBX systems | |||
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Tablet computers | Tablet computers | |||
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Touch screen monitors | Touch screen monitors | |||
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Typewriters | Typewriters | |||
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Prerequisite Qualification Category | Education and Experience Level | |||
Required Level of Education | High School Diploma (or GED or High School Equivalence Certificate) | |||
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Related Work Experience | None | |||
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On-Site or In-Plant Training | None | |||
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On-Site or In-Plant Training | Up to and including 1 month | |||
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On-the-Job Training | Anything beyond short demonstration, up to and including 1 month | |||
On-the-Job Training | Over 1 month, up to and including 3 months | |||
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Alternate Job Title(s) | |||
Administrative Support Assistant | |||
Bill Pay Clerk | |||
Cancer Registrar | |||
Certified Coding Specialist | |||
Certified Medical Coder | |||
Certified Professional Coder (CPC) | |||
Clerk | |||
Clinical Analyst | |||
Clinical Data Specialist | |||
Clinical Office Technician | |||
Clinical Secretary | |||
Coder | |||
Compliance Coordinator | |||
Disability Rater | |||
File Clerk | |||
Filer | |||
Health Data Analyst | |||
Health Informatics Specialist | |||
Health Information Administrator | |||
Health Information Clerk | |||
Health Information Coder | |||
Health Information Management Clerk | |||
Health Information Management Specialist | |||
Health Information Management Technician | |||
Health Information Specialist | |||
Health Information Systems Technician | |||
Health Record Technician | |||
Health Records Technician | |||
Health Services Information Specialist | |||
Health Unit Clerk | |||
Hipaa Compliance Officer | |||
Historian | |||
Hospital Unit Clerk | |||
ICD-9 Coder (International Classification of Diseases Coder) | |||
Insurance Coder | |||
Library Historian | |||
Medical Administrative Specialist | |||
Medical Administrative Technician | |||
Medical Biller Coder | |||
Medical Billing Coder | |||
Medical Billing Specialist | |||
Medical Billing and Coding Specialist | |||
Medical Care Evaluation Specialist | |||
Medical Claims Processor | |||
Medical Clerk | |||
Medical Coding Technician | |||
Medical Data Analyst | |||
Medical Insurance Coder | |||
Medical Insurance Coding Specialist | |||
Medical Office Technician | |||
Medical Record Assistant | |||
Medical Record Coder | |||
Medical Record Consultant | |||
Medical Record Specialist | |||
Medical Records Analyst | |||
Medical Records Clerk | |||
Medical Records Coordinator | |||
Medical Records Custodian | |||
Medical Records Director | |||
Medical Records Manager | |||
Medical Records Specialist | |||
Medical Records Technician | |||
Medical Reimbursement Specialist | |||
Medical Secretary | |||
Medical Transcriptionist | |||
Office Manager | |||
Public Health Registrar | |||
Receptionist | |||
Registered Health Information Technician (RHIT) | |||
Release of Information Specialist | |||
Severity of Illness Coordinator | |||
Tumor Registrar | |||
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