Participates in and provides lead direction over staff performing clerical work in maintaining medical chart files; receives, prepares and processes the release of medical information and subpoena processes, and maintains records in compliance with regulatory requirements.
This is an advance journey/lead level classification, characterized by the responsibility to perform work requiring the application of technical knowledge related to the management of health care records. The employee ensures adherence to established policies, procedures, laws and regulations and to proper maintenance and storage methods. The incumbent works with independence in coordinating medical records activities in accordance with established policies and guidelines and has some latitude in decision making to apply broader aspects of established practices and procedures. This classification is distinguished from the Medical Records Technician by providing technical and functional oversight and on-the-job training to that class and performing the more complex work of the unit.
Supervision Received and Exercised
Receives direction from professional, supervisory or management level staff.
Provides technical and functional oversight to technical/clerical staff.
Examples of Duties
Plans, assigns, reviews, oversees and performs the work of technical/clerical staff in performance of medical records duties; trains new staff in medical records maintenance, policies and procedures; assists in the selection of subordinate personnel; provides input into employee work performance evaluation.
Creates documents to collect patient data; compares patient care data with other informational sources; summarizes information from patient records for completion of coordination or service plans; checks data for internal consistency; prepares data for analysis; performs edit checks to monitor data accuracy; collects data on the quality of documentation in the medical records.
Oversees and maintains general filing for all closed chart records; reviews files, records and documents for accuracy, completeness and consistency of information recorded; sorts, stores and retrieves documents, records, charts, materials and other items by alpha, numeric, content or other classification method; locates missing material through conducting a file search.
Receives requests for and locates medical information, records, charts and materials; records distribution information; prints medical information stored on electronic media or microfilm; distributes files, materials and information using inter/intra-office mail, electronic mail, courier or post office.
Searches for misplaced medical records, charts and materials; uses indices and cross-references and/or conducts search of manual, microfilm or electronic information storage systems to locate information.
Pulls charts daily for physicians’ next day appointments, medication monitoring/compliance, signed and dated consent forms, and chart compliance with County and State regulations; receives and prepares order; assists with chart pulls for walk-in appointments; updates information in charts; prepares and processes documents for Mental Health Medical Records, including Children and Adult programs.
Ensures that old charts are destroyed according to department policy and regulatory requirements; receives charts throughout the day for refiling; verifies closed records in computer data base; distributes weekly and monthly reports to units and departments.
Confers and responds to court, staff, and/or public inquiries regarding Mental Health issues according to Health and Social Services policies and procedures.
Responds to subpoenas and legal questions regarding medical records; screens subpoenas for appropriateness; keeps a log of all information released; communicates with attorneys and other interested parties regarding legal questions relating to County medical records; researches medical records in response to legal questions and inquiries; makes Court appearances when necessary.
Assists in the development, implementation and review of policies and procedures for medical records maintenance in conformance with state and federal regulations; monitors compliance with legal requirements; assists in updating policies and procedures as necessary.
Oversees implementation of departmental services and operational systems and information systems for patient-related data; evaluates the effectiveness of the medical records program and makes suggestions for improvement.
Provides input into operational systems for information retention and retrieval including the determination of space requirements; monitors and tracks location of medical records; compiles and updates system on the status of closed charts.
Answers and screens telephone calls for appropriate information; forwards calls to appropriate individual or office; provides requested charts for doctors and other staff members; receives information by written correspondence, telephone, or fax; prepares order forms for clerical supplies.
Monitors the entry of utilization control data for accuracy; assists staff with utilization control data problems; explains how to resolve/correct problems; designs electronic forms.
Confers with doctors, nurses and other health care personnel in order to assure complete, current and accurate medical records.
Provides technical or staff assistance for special projects and assignments; may type medical data, forms, memos or other documents.
Knowledge, Skills & Abilities
Principles, practices, regulations and terminology relating to medical records management.
Legal requirements and limitations pertaining to the release of medical information.
Current technology and equipment utilization involving data collection, storage and retrieval.
Data collection and compilation techniques.
Supervisory techniques used in planning, assigning, and reviewing the work of staff.
Office procedures and practices; work organization and simplification; principles and practices of record keeping.
Principles and techniques of medical record auditing and data collection. Skill to:
Operate office equipment including a personal computer, copy and fax machines and printers. Ability to:
Plan, assign and oversee the work of staff; organize and prioritize work assignments.
Implement and maintain manual and automated medical record keeping systems.
Prepare and present clear and concise recommendations on medical records issues; conduct records management surveys and prepare written reports; collect and review data to establish/identify needs and draw logical conclusions and make appropriate recommendations; review regulations, procedures and/or reference materials.
Coordinate medical records maintenance on a timely basis.
Provide information to agency managers regarding records management issues.
Maintain accurate records and document actions taken.
Use proper grammar, spelling and punctuation; maintain confidentiality of information.
Communicate effectively both verbally and in writing with people of diverse socio-economic backgrounds and temperaments; demonstrate tact and diplomacy; establish and maintain cooperative working relationships.
Education and Experience
Two (2) years of work experience in which medical records management was a primary responsibility; experience providing technical and or functional assistance to less experienced staff is desirable. Education/Training:
High school diploma or GED; current certification as an Accredited Records Technician (ART) with the American Health Information Management Association (AHIMA) is desirable.
Independent travel may be required.
Possession of or ability to obtain a valid Class C California driver’s license may be required.
Physical Ability: Tasks involve regular and sustained performance of moderately physically demanding work, typically involving some combination of climbing and balancing, stooping, kneeling, crouching, and crawling, and that generally involves lifting, carrying, pushing, and/or pulling of moderately heavy objects and materials (20-50) pounds. Some tasks may involve extended periods of time at a keyboard or work station. Sensory Requirements: Some tasks require visual perception and discrimination. Some tasks require oral communications abilities.
Environmental Factors: Tasks are regularly performed without exposure to adverse environmental conditions, such as dirt, dust, pollen, odors, wetness, humidity, rain, fumes, temperature and noise extremes, machinery, vibrations, electric currents, traffic hazards, toxic agents, violence, disease, or pathogenic substances.