MEDICAL RECORDS TECHNICIAN SENIOR 32112

02/16/90 C

This is the second class in the Medical Records series for classes that are responsible for maintaining medical records and medical data in a variety of agencies and institutions. Positions assigned to this class perform work in a medical environment which is large, complex, and self-contained, or in a medical unit of an institution or agency whose primary function is other than medical care. Positions in this class may be one of several lead workers in a complex environment or the single lead position in smaller medical units. This class is distinguished from the Medical Records Technician class by its lead worker responsibilities and by its greater complexity and scope of duties. It is distinguished from the Medical Records Supervisor class which supervises others, and has more responsibility for overall unit functioning, and administrative duties.

Complexity of Work: Performs work of moderate difficulty, which involves preparing and reviewing abstracts; serving as project leader for major coding activities; collecting and preparing data for internal or external review, analysis, and reporting; and/or tracking illness-specific patients with regard to recuperation, stabilization, regression, or death. Positions may specialize in an assigned area(s) of medical records activities; or may be the primary contact person for accounts receivable or insurance personnel to reconcile diagnosis and treatment with related costs/charges. May be responsible for admissions and/or discharge records; timely retrieval of records; filing, storage and security of inactive files; manual maintenance; and for responding both orally and in writing to proper requests for information from files. May be subpoenaed to testify in judicial, quasi-judicial, or administrative hearings; or to make statements in less formal settings where the accuracy or completeness of the records are in question. When functioning as lead workers, positions are responsible for informal training of new employees; and may temporarily fulfill supervisory functions in the absence of the supervisor or administrator. Reviews work products of lower level or new personnel to determine accuracy before it is passed to the supervisor for review. Positions may be responsible for the interpretation of rules, policies and procedures in smaller work environments. Prepares or reviews abstracts to assure inclusiveness and/or sequential correctness of data; and returns records to person or point of origin to have corrections made.

Supervision Given: Supervision is typically not a factor; however, positions typically function as lead workers.

Supervision Received: Receives general supervision from a Medical Records Supervisor or Manager, physician, nursing administrator or supervisor, or other agency official.

Scope: Positions in this class perform work which supports and facilitates the establishment, maintenance, usage, and disposition of medical information. The creation of records is confined to the organization, but the contents could be used by several external organizations or individuals at various levels.

Impact of Actions: Incorrect or incomplete data could result in erroneous diagnoses, treatment, reporting, research, education, and administrative decisions, thereby threatening the reputation of the organization and increasing the degree of liability.

Personal Contacts: Frequent internal contact with various agency personnel and infrequent external contacts with courts, law enforcement officials, insurance carriers, medicaid/medicare interviewers, legal or social agency representatives, and external physicians to provide or obtain medical records information.

Knowledges: Working knowledge of policies, regulations and practices related to medical records preparation,maintenance, usage, and disposition; of extensive medical and surgical terminology; of disease processes; of medical information management; and of disease classification systems and medical coding.

Skills: Working skill in the operation of a computer keyboard may be required.

Abilities: Demonstrated ability to review and organize amounts of detailed technical data; to lead the work of others; and to work well with individuals seeking/providing medical records information.

Licenses or Certification: None.

Education or Training: Graduation from high school or equivalent and completion of an approved program of instruction for medical records technician.

Level and Type of Experience: Experience related to recordkeeping of medical records or health information, maintenance of files/documents, and information systems.

An equivalent combination of training and experience indicating possession of the preceding knowledges and abilities may substituted for this education and experience.

This class, along with the Medical Records Supervisor class, replaces the Medical Records Administrator A class. It was established as a result of the statewide Classification Review/Specification Update Program, effective February 1990.