Performs technical and supervisory work in coordinating medical records programs; develops and implements policies and procedures for the assigned medical records unit(s); processes and maintains records in compliance with regulatory requirements.
This is a first line supervisor 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 considerable independence in coordinating medical records activities in accordance with established policies and guidelines.
Supervision Received and Exercised
Receives direction from professional or management level staff.
Provides supervision over technical/clerical staff.
Examples of Duties
Supervises and backs-up technical/clerical staff in performance of medical records duties; trains new staff in medical records maintenance, policies and procedures; interviews and assists in the selection of subordinate personnel; evaluates work performance; sets goals and standards for the unit;
Develops, implements and reviews policies and procedures for medical records maintenance in conformance with state and federal regulations; monitors compliance with legal requirements; updates policies and procedures as necessary.
Executes plans for implementing 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.
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.
Designs departmental operational systems for information retention and retrieval including the determination of space requirements; determines feasibility and constraints applicable to design or redesign of the department’s operational systems; monitors and tracks location of medical records; compiles and updates system on the status of closed charts.
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.
Attends Utilization Review meetings; audits Utilization Review documents for completeness and appropriateness; reviews and verifies disallowances identified by reviewers and notifies accounting section to adjust billing accordingly.
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 the selection, training, supervision and discipline of staff.
Office procedures and practices; work organization and simplification; principles and practices of record keeping. Skill to:
Operate office equipment including a personal computer, copy and fax machines and printers. Ability to:
Plan, assign and supervise 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 analyze data to establish/identify needs and draw logical conclusions and make appropriate recommendations; research regulations, procedures and/or technical reference materials.
Coordinate medical records maintenance on a timely basis.
Provide consult to agency managers regarding records management issues.
Develop unit objectives in relation to departmental goals and procedures.
Make decisions and independent judgments; determine the appropriate course of action in stressful situations.
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
Three (3) years full-time work experience in medical records management, including eighteen (18) months providing technical and or functional assistance to less experienced staff 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.
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.
Independent travel may be required.
Possession of or ability to obtain a valid Class C California driver’s license may be required.