Under general supervision, codes diseases and medical procedures using the standard classification system; and does related or other work in accordance with Rule 3, Section 3, of the Civil Service Rules.
This is the journey level class in the Medical Records Technician series. An employee of this class codes inpatient as well as outpatient medical information and may perform other special assignments as related to the medical records division. 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; gives out 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.
Keeps 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.
Licenses & Certificates: Possession of certification as a Certified Coding Specialist, issues by American Health Information Management Association.
Experience: One-year equivalent to a Medical Records Technician I in San Joaquin County.
Experience: Four years of office clerical work in a medical records department of an acute care hospital, mental inpatient facility, skilled nursing facility, or large group practice/medical clinic, one year of which must have included coding diseases and medical procedures using the standard classification system.
Medical record keeping principles and practices, including familiarity with standard nomenclature and classification; 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.
Perform specialized and routine clerical work; prepare reports based on information derived from medical records; 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; sit, and/or stand, for extended periods of time; stoop, kneel, bend, and reach overhead to retrieve files from shelves; carry stacks of files; maneuver in narrow spaces.
Mobility-Frequent operation of a data entry device, repetitive motion, sitting for long periods, walking; occasional standing, pushing, pulling, bending, 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, and concentration; Special Requirements-some assignments may require working weekends, nights, and/or occasional overtime; Environmental-Occasional exposure to varied weather conditions.