PURPOSE OF JOB CLASS (NATURE OF WORK)
In a state medical institution or facility medical records department this class is accountable for independently performing a full range of tasks associated with maintaining medical records and medical records coding activities.
Works under the general supervision of a Medical Records Supervisor or other employee of higher grade.
May lead lower level clerical employees as assigned.
EXAMPLES OF DUTIES
Assists in maintaining a file of medical records such as daily admissions and discharges, daily census, case histories, results of diagnostic tests, signed releases of information, medical summaries and abstracts; inspects reports and records for omissions and errors; codes and files a full range of diagnoses according to anatomical systems and in conformance with accepted international classification systems (i.e. ICD, WHO, DSM3, DRG, etc.); prepares statistical reports on such matters as classification of disease, laboratory, dental, X-ray and physiotherapy activities; prepares death certificates, burial permits and other related records; prepares reports to state and federal agencies as required; may attend probate court hearings and give testimony; performs related duties as required.
KNOWLEDGE, SKILL AND ABILITY
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 principles of statistical data tabulation; knowledge of office systems and procedures; oral and written communication skills; basic interpersonal skills.
MINIMUM QUALIFICATIONS - GENERAL EXPERIENCE
Four (4) years of experience in the maintenance of medical records and preparation of statistical reports.
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 in Salary Group CL 14 approved effective May 26, 2009. (Revised to change Service Status to Classified/Non-Competitive and remove Substitutions Allowed)