Under immediate supervision, codes diseases and medical procedures using the standard classification systems; and does related or other work in accordance with Rule 3, Section 3, of the Civil Service Rules.
This is the entry-level class in the Medical Records Technician series. An incumbent of this class learns to code medical information from outpatient medical records. As experience is gained, the incumbent learns to code the more difficult inpatient medical information. An incumbent may also serve in a lead worker capacity over the clerical staff of a division responsible for the maintenance of a large collection of medical and/or psychiatric case histories.
Assembles and maintains medical record charts and files; codes diseases and medical procedures using the standard classification system; prepares input for computerized medical information system; processes vital statistics, disability insurance, and other forms and documents.
Maintains statistical and computerized reports and indexes on health data; researches same to locate health data, information requested by physicians, health care accrediting agencies and others.
Screens requests for release of medical information from medical records; distributes authorized information to physicians, hospital personnel, attorneys, insurance companies, and others; accepts and responds to court subpoenas; may appear in court to give testimony on medical records.
Maintains records and prepares reports and correspondence as required.
May provide direction, answer questions, and resolve problems of clerical staff of a medical records division of San Joaquin County Health Care Services.
May analyze medical charts for comparison against clinical indicators; identify deviations from indicators; prepare reports for presentation to the medical staff and administration.
Education:Successful completion of a coding certificate program for ICD-9 and CPT-4.
Experience:Two years of clerical or technical work in a medical setting such as an acute-care hospital, mental health inpatient facility, skilled nursing facility, or large group-practice/medical clinic.
Substitution:Successful completion of accredited college level course work in anatomy and physiology and medical terminology may be substituted for one year of the experience requirement.
Medical terminology, anatomy and physiology, and disease processes; abstracting medical records according to ICD-9, CPT-4 and HCPCS coding guidelines;medical recordkeeping principles and practices, including familiarity with standard nomenclature and classification; basic computer and modern office automation technology and computer software programs relevant to department operations; functions of a medical records department; legal aspects of medical record administration; nature and uses of medical records charts; the business and professional relationships and ethics involved among hospitals, physicians, and patients.
Learn to apply proper coding guidelines; accuracy in coding assignment and reimbursement; perform specialized and routine clerical work; prepare reports based on information derived from medical records; operate computers, office equipment and related software; make independent decisions in procedural matters; establish and maintain effective working relationships with other employees, physicians, and the general public; communicate effectively, both orally and in writing.
Mobility-Frequent operation of a data entry device, repetitive motion, sitting and standing for long periods, walking; occasional pushing, pulling, bending, stooping, squatting, climbing; Lifting-Frequently 5 pounds or less; occasionally 5 to 30 pounds; Visual-Constant good overall vision and reading/close-up work; frequent color perception and use of eye/hand coordination; occasional use of depth perception and peripheral vision; Hearing/Talking-Frequent hearing of normal speech, hearing/talking on the telephone, talking in person; Emotional/Psychological-Decision making; concentration; occasional exposure to trauma, grief and death. Special Requirements-Some assignments may require working weekends, nights, and/or occasional overtime; Environmental-Occasional exposure to varied weather conditions.