CLASS TITLE:                           MEDICAL RECORDS TECHNICIAN

CLASS DEFINITION:

GENERAL STATEMENT OF DUTIES:

This is a Supervisory position in the medical record keeping/coding series. Plans, assigns, supervises and reviews the work of clerical, technical and stenographic staff in a medical records program; Work involves the independent preparation, compilation, maintenance and coding of medical records for patients or clients of a  state agency; and to do related work as required.

SUPERVISION RECEIVED:

Works under the supervision of a Director of Medical Records, a senior manager, or other superior. Routine tasks are performed independently, work is reviewed upon completion for conformance to policies, objectives, rules, regulations and medical records science standards required for accreditation.

SUPERVISION EXERCISED:

This is a supervisory class. Plans, assigns, supervises, and reviews the work of a medical records staff.

ILLUSTRATIVE EXAMPLES OF WORK PERFORMED:

To plan, assign, supervise and review the work of clerical, technical and stenographic staff in a medical records program.

Utilizes and supervises the utilization of automated systems in all relevant aspects of the medical records program.

To prepare, compile, maintain and file medical records.

Participates in and supervises the preparation of various reports.

Participates in and supervises the preparation of case abstracts, histories and other pertinent medical records data.

Supervises patient admission and discharge procedures related to medical records, as required.

Analyzes aggregate data.

Records appropriate codes onto reporting forms.

Reviews reporting forms for completeness.

Contacts agencies to obtain required information.

Refers to master code list to obtain correct codes for posting to recording form.

Consults with computer personnel on changes in program reporting system.

Explains the reporting system to participating agencies.

Mails semi-annual and annual data reports to agencies.

Provides technical assistance to agency personnel.

Serves as records contact person for various programs.

Assists in designing new forms.

Adheres to JCAHO standards, federal and state laws and hospital procedures.

Visits outside agencies to audit patient charts.

Maintains a file for all reporting forms to verify payments.

Audits patient charts to determine the type and nature of services provided.

Calculates a mathematical score to indicate services provided.

Prepares basic business correspondence.

Maintains a daily log to record preventive services

Orders and distributes reporting forms to agencies.

Participates in hospital departmental meetings, as required.

Assists in the training of medical records program staff.

As required, maintains and safeguards the confidentiality, security and physical safety of patients' records.

As required, provides for the processing of subpoenas and depositions consistent with applicable legal regulations and state policies.

As required, interviews and selects new personnel; evaluates staff competency and conducts staff meetings.

As required, provides consultation and counseling on Advance Directives.

As required, oversees the appointment function for a facility.

Performs related work as required.

REQUIRED QUALIFICATIONS FOR APPOINTMENT:

KNOWLEDGE, SKILLS AND CAPACITIES:

A working knowledge of medical record keeping principles, practices and procedures involving the collection, cataloging, classification, coding, indexing and filing of medical information and data; knowledge of medical terminology and standard classified nomenclature of diseases, illnesses and causes of death, and the ability to apply such knowledge in medical records; a working knowledge of the application and use of automation in a medical records program; and related knowledge, skills, abilities and capacities.

EDUCATION AND EXPERIENCE:

EDUCATION:

Graduation from a senior high school and supplemented by course work recognized by the American Health Information Management Association for medical records personnel and/or recognized supplemental course work in medical office management with concentration on medical records management and coding; and 

EXPERIENCE:

Prior work should include activities such as: Employment in preparing, compiling coding and maintaining medical records

Or, any combination of education and experience that shall be substantially equivalent to the above education and experience.