Medical Records Specialist (#MAAG01)
$34,240.00 Yearly Min / $42,800.00 Yearly Mid / $51,360.00 Yearly Max

Medical Records Administrator (#MAAG02)
$46,714.00 Yearly Min / $58,393.00 Yearly Mid / $70,072.00 Yearly Max

Employees in this class series are responsible for maintaining medical records for state medical facilities and health programs from creation to final preservation or disposal. Primary work involves ensuring the efficient and accurate management of medical records to provide essential data to clinicians and for billing purposes.

Medical records work is performed in compliance with best practices and applicable state and federal laws, rules, and regulations. In addition, employees must apply procedures on security, patient confidentiality, and authorized user access when releasing medical records and information. Work requires the regular use of office equipment, automated information systems, and computer software. Work also requires employees to understand medical terminology and use specialized medical classification and categorization software.

Essential functions are fundamental, core functions common to all positions in the class series and are not intended to be an exhaustive list of all job duties for any one position in the class. Since class specifications are descriptive and not restrictive, employees can complete job duties of a similar kind not specifically listed.

• Coordinates and maintains medical records, including physical, electronic, and digital files, documentation, and reports.
• Applies and ensures compliance with best practices, and applicable state and federal laws, rules, and regulations, including procedures on security, patient confidentiality, and authorized user access of medical records.
• Reviews and evaluates patient data, medical history, exam/test results, treatment or services provided, billing, and other information to ensure completeness and accuracy. Resolves discrepancies, deficiencies in information, or other issues.
• Codes and records diagnoses of diseases, operations, illnesses and special therapies in accordance with the specific nomenclative and classification system.
• Transcribes medical dictation.
• Opens, maintains, and closes records; scans, uploads, logs, indexes, and files pertinent documents and information.
• Creates and maintains a variety of record-keeping systems or logs to file, track, and retrieve documents or other information.
• Receives and transfers medical records and reports and responds to requests to release medical information, ensuring the request is valid and authorized.
• Coordinates and schedules services such as patient or client testing, treatment, referrals, appointments, admission, or discharge.
• Uses automated information systems and computer software, including medical classification and categorization software, to enter, update, modify, delete, retrieve, and report on data.
• Performs office support activities such as preparing and distributing correspondence, billing, payment, or other documents; or creating, maintaining, updating, and merging documents or data.
• Prepares records for preservation, storage, or disposal in accordance with legal and related requirements.
• Performs other related duties as required.

The level of work for an employee in this class series progresses based on an employee’s independence, size and scope of responsibilities, complexity of duties, decisions made, and required experience.

Medical Records Specialist

This is the first level, performing medical records work for state medical facilities and health programs. Employees independently perform the full range of Essential Functions under general supervision. 

• Receives general supervision from a technical supervisor; the supervisor provides general direction on all assignments, and regular review of progress, accuracy, and quality of work. Supervisory advice or assistance is provided as needed.
• Researches discrepancies by retrieving and examining original records for missing information or errors. Notifies supervisor of reoccurring errors to make improvements.
• Makes standard corrections or updates to information on medical records or recommends action for more complex discrepancies.
• May assist with audits of medical records and related documentation.
• Communicates effectively with department, healthcare, or hospital staff, various state and federal agencies, insurance companies, patients, and the public to gather, clarify, and relay information.

Medical Records Administrator

This is the second level of medical records work, administering a medical records program for a large facility or state registry.

• Receives minimal supervision from an administrative supervisor; the supervisor defines objectives, priorities, and deadlines and assists the employee with unusual situations.
• Plans and directs medical records operations and staff which includes supervising two or more merit full time positions. The elements of supervision include performing the following on a regular and continuing basis: planning, assigning, reviewing, evaluating, coaching, training, disciplining, and recommending hire, termination, and promotion.
• Provides technical guidance on the reporting, classification, security, and confidentiality of medical records data and resolves escalated issues.
• Plans, develops, and implements medical records systems for documenting, storing, and retrieving information and for processing medical-legal documents.
• Ensures operational compliance and quality through internal audits and reviewing and evaluating records systems, performance, equipment, and reporting.
• Recommends or implements new or revised processes and procedures, or other improvements, that facilitate effectiveness and compliance.
• May support audits by providing medical record information to management.
• Communicates effectively with department, healthcare, or hospital staff, various state and federal agencies, legal or law enforcement agencies, insurance companies, patients, and the public to obtain, clarify, and provide information. 

JOB REQUIREMENTS for Medical Records Administrator
Applicants must have education, training and/or experience demonstrating competence in each of the following areas:

1. One year of experience in medical records management such as managing the maintenance, storage, retrieval, retention, and disposal of medical records throughout the life span of the records.
2. One year of experience in reviewing and evaluating medical records for completeness and accuracy and resolving deficiencies in information.
3. Six months’ experience in applying laws, rules, regulations, standards, policies, and procedures. 
4. Coursework, training and/or work experience in staff supervision which may include performing as a lead worker overseeing the work of others.