PURPOSE OF JOB CLASS (NATURE OF WORK)
In a state medical institution or facility medical records department this class is accountable for performing the most complex tasks associated with maintaining medical records and medical records coding activities.
GUIDELINES FOR JOB CLASS USE
This class is intended to be used in one of two ways:
1. As the sole Medical Records Specialist, of whom may be supported by a Medical Records Clerk, in a small facility.
2. As the advanced working level in a large institution or facility.
Works under the limited supervision of a Medical Records Supervisor or other employee of higher grade.
May lead lower level employees as assigned.
EXAMPLES OF DUTIES
Performs highly technical duties in establishment, retention and maintenance of a filing system of medical records such as daily admissions and discharges, daily census, case histories, results of diagnostic tests, medical summaries, abstracts and signed releases of information; ensures compliance with The Joint Commission (TJC) and Title XIX standards; prepares records for clinicians use; analyzes medical records and contents for completeness and quality; prepares medical and statistical reports (patient diagnostic and demographic information, census log, discharge information, etc.); may microfilm medical records; may attend probate court hearings and give testimony; performs related duties as required.
KNOWLEDGE, SKILL AND ABILITY
Knowledge of relevant state and federal laws, statutes and regulations; knowledge of basic medical terminology and human anatomy; knowledge of medical coding principles and techniques with particular emphasis on International Classification of Disease Adopted procedures; knowledge of The Joint Commission (TJC) medical records standards; knowledge of principles of statistical data tabulation; knowledge of office systems and procedures; interpersonal skills; oral and written communication skills; ability to maintain medical records and prepare reports; ability to utilize computer software.
MINIMUM QUALIFICATIONS - GENERAL EXPERIENCE
Five (5) years of experience in the maintenance of medical records and preparation of statistical reports.
MINIMUM QUALIFICATIONS - SPECIAL EXPERIENCE
One (1) year of the General Experience must have been as a Medical Records Specialist 1 or its equivalent.
Persons having responsibility for supervising or observing the behavior of inmates or custodial clients will be required to possess a high school diploma or General Educational Development (GED) certification by the time of permanent appointment.
JOB CLASS DESIGNATION
(07)-ADMN CLERICAL (NP-3)
This replaces the existing specification for the class of Medical Records Specialist 2 in Salary Group CL 18 approved effective May 26, 2009. (Revised to change Service Status to Classified/Non-Competitive and remove Substitutions Allowed)