County of Alameda

DESCRIPTION

Under direction, to code and abstract diagnoses and procedures according to the latest adaptation of the International Classification of Diseases Coding (ICD-9 CM or ICD-10CM) classification system; to compile statistical indices and data sources used for research studies, medical audits and other statistical reports; and to perform related duties as required.


DISTINGUISHING FEATURES

This is a para-professional classification located within the Health Care Services Agency’s Public Health Department’s, California Children’s Services Program. Incumbents in this class receive supervision from a Patient Records Manager. The Medical Records Technician differs from the higher-level class of Patient Records Manager in that the latter class has day-to-day management and supervisory responsibilities. This class differs from the next lower-level class of Medical Clerk in that Medical Records Technician requires technical training in and knowledge of the current version of the International Classification of Diseases Coding Systems, medical terminology, anatomy, and physiology in order to perform assigned duties.

EXAMPLES OF DUTIES

NOTE: The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Each individual in the classification does not necessarily perform all duties listed.

1. Requests medical reports and compiles medical records data for chart content and required documentation; analyzes medical information to determine appropriate medical codes according to the latest adaptation of the International Classification of Diseases Coding System (ICD-9CM or ICD-10CM) and enters information into a computer database system.

2. Maintains confidential medical records on patients with sensitive diagnoses and trauma.

3. Assists professional medical personnel in the procedures and practices of completing medical information, such as entering ICD-9CM or ICD-10CM coding, processing service authorization requests, and sending correspondence to families and providers.

4. Reviews medical record reports for clarity and accuracy. Consults with medical staff as needed and contacts providers for service request clarifications.

5. Uses computer to enter and update all patient information, issues letters and authorizations for services and requests appropriate information to complete case management activities.

6. May assist with release of information activities and other medical-legal duties; performs special projects as assigned.

7. Prepares paperwork for transfer of clients; reviews and distributes documents received via U.S. mail, faxes, email, etc.; creates and modifies charts; files medical documentation in clients’ charts.

8. Answers telephone calls from providers, clients, and other professional staff; screens calls, greets clients, provides appropriate and accurate information, and delivers messages.

9. Attends program related meetings; assists in the review and development of operating procedures.

10. Performs related duties as required.

MINIMUM QUALIFICATIONS

Education:

Successful completion of coursework in medical terminology, human anatomy and physiology.

And Either I
Experience:

The equivalent of one-year recent, within the last five (5) years, full-time experience as a Public Health Nursing Assistant, or in an equivalent or higher level class, that included work with medical terminology and knowledge of medical record content in the Alameda County classified service (non-classified includes District Attorney’s Office, Hospital Authority, and the Consolidated Courts).

Or II
Experience:

The equivalent of one-year recent, within the last five (5) years, full-time medical clerical experience that required using and interpreting a wide variety of medical terminology in ICD-9CM or ICD-10CM coding, in a physician’s office, hospital, medical clinic or a medical billing setting.

NOTE: The Civil Service Commission may modify the above Minimum Qualifications in the announcement of an examination.

KNOWLEDGE AND SKILLS

NOTE: The level and scope of the following knowledge, skills and abilities are related to duties listed under the "Examples of Duties" section of this specification.

Knowledge of:

• Current adaptation of the International Classification of Diseases coding system used for coding and classifying diseases, diagnoses and medical procedures (i.e., ICD-9CM or ICD-10CM).
• Components and format of medical records.
• Medical terminology
• Basic human anatomy and physiology.
• Statistical techniques used for compiling, displaying and analyzing data.
• Current HIPPA regulations regarding privacy, security and confidentiality as it pertains to Protected Health Information (PHI).
• Microsoft Word, Outlook, Excel and data entry programs.

Ability to:

• Read and comprehend the technical elements of a medical record.
• Analyze and code medical records at a 95% accuracy level.
• Recognize and follow up inconsistencies in medical records.
• Prepare clear and concise narrative, statistical, and graphic reports.
• Communicate clearly and professionally with staff, families and providers.
• Communicate clearly and effectively in English both verbally and in writing.
• Provide and promote excellence in customer service for both internal and external customers.
• Work on a computer database system; learn to load software and back up data.
• Set work priorities and work independently; exercise considerable independent judgment.
• Lift, move and/or carry up to ten (10) lbs., as well as working sitting or standing for extended periods of time.

CLASS SPEC HISTORY

Revised: 7/80
JG-S:gcb
Revised/Retitled: 12/88
TMZ:pb
Old document: 0168h
New document: Jobspecs/1460
ys/5/01
CSC Date: 1/4/89
JS:cs Revised 8/16/11
CSC Date: 09/07/11
AS:cs Revised 6/10/15
CSC Date: 6/24/15
SJ:cs Revised 11/16/15
CSC Date: 1/6/16

BENEFITS

Alameda County offers a comprehensive and competitive benefits package that affords wide-ranging health care options to meet the different needs of a diverse workforce and their families. We also sponsor many different employee discount, fitness and health screening programs focused on overall well being.  These benefits include but are not limited to*:

For your Health & Well-Being

• Medical – HMO & PPO Plans
• Dental – HMO & PPO Plans
• Vision or Vision Reimbursement
• Share the Savings
• Basic Life Insurance 
• Supplemental Life Insurance (with optional dependent coverage for eligible employees) 
• County Allowance Credit
• Flexible Spending Accounts - Health FSA, Dependent Care and Adoption Assistance
• Short-Term Disability Insurance
• Long-Term Disability Insurance
• Voluntary Benefits - Accident Insurance, Critical Illness, Hospital Indemnity and Legal Services
• Employee Assistance Program

For your Financial Future

• Retirement Plan - (Defined Benefit Pension Plan)
• Deferred Compensation Plan (457 Plan or Roth Plan)

For your Work/Life Balance

• 12 paid holidays
• Floating Holidays
• Vacation and sick leave accrual
• Vacation purchase program
• Catastrophic Sick Leave
• Pet Insurance
• Commuter Benefits Program
• Guaranteed Ride Home
• Employee Wellness Program (e.g. At Work Fitness, Incentive Based Programs, Gym Membership Discounts)
• Employee Discount Program (e.g. theme parks, cell phone, etc.)
• Child Care Resources
• 1^st United Services Credit Union 

*Eligibility is determined by Alameda County and offerings may vary by collective bargaining agreement.  This provides a brief summary of the benefits offered and can be subject to change.