State of Maryland

A Health Records Reviewer is the full performance level of work reviewing health records in order to make recommendations concerning the duration and continuation of patients' stays in a State facility or local health department and to ensure compliance with facility policies.  Employees in this classification do not supervise other positions.

Employees in this classification receive general supervision from a Registered Nurse or a designated administrator.

Positions in this classification are evaluated by using the classification job evaluation methodology.  The use of this method involves comparing the assigned duties and responsibilities of a position to the job criteria found in the Nature of Work and Examples of Work sections of the class specification.

The Health Records Reviewer is differentiated from the Health Records Technician II in that the Technician II is the full performance level of work compiling and maintaining health records in a State facility or local health department. 

Reviews health records to include ward charts, physicians' orders, nursing care plans, and treatment logs for individual patients to ensure that all information has been entered appropriately;

Evaluates patient health records to determine if the criteria for admission and continued hospital stay have been met;

Reviews physicians' orders and treatment plans to ensure that they are consistent with diagnoses;

Completes use review worksheets to determine that the care and treatment has been provided according to established criteria;

Testifies in court and hearings;

Contacts physicians and other professional clinical staff to exchange information regarding the appropriateness of patient care;

Prepares reports of deficiencies found in patient health records for the review of clinical staff;

Participates in multi-disciplinary Utilization Review Committee meetings to discuss and evaluate findings that include issues of utilization, readmissions, adequacy of discharge planning and compliance with hospital policies;

Performs other related duties.

Knowledge of standard English and grammar;

Knowledge of medical diagnoses and appropriate treatments;

Knowledge of medical and general clinical terminology;

Knowledge of relevant federal, State and local regulations governing medical records;

Knowledge about diseases and their effects and treatment;

Knowledge of hospital administration and organization;

Knowledge of the standard treatments and tests to be administered for specific diseases;

Ability to code and index medical information according to recognized procedures;

Ability to prepare and compile medical reports and statistics;

Ability to perform basic mathematics;

Ability to establish and maintain effective relationships with staff members and the public and to advise them of medical records matters;

Ability to communicate effectively with co-workers, supervisors, and the general public.

Education:   Graduation from an accredited high school or possession of a high school equivalency certificate.

Experience: Three years of experience compiling and maintaining health records.

Notes:

1. Candidates may substitute additional experience on a year-for-year basis for the required education.

2. Candidates may substitute U.S. Armed Forces military service experience as a non-commissioned officer in Medical Record classifications or Patient Administration Specialists and Health Services Management specialty codes in the health records management field of work on a year-for-year basis for the required experience.

Class specifications are broad descriptions covering groups of positions used by various State departments and agencies. Position descriptions maintained by the using department or agency specifically address the essential functions of each position.

This is a Skilled Service classification in the State Personnel Management System.  All positions in this classification are Skilled Service positions.  Some positions in Skilled Service classifications may be designated Special Appointment in accordance with the State Personnel and Pensions Article, Section 6-405, Annotated Code of Maryland.

This classification is assigned to Bargaining Unit D- Health and Human Service Non-Professional classes.  As provided by State Personnel and Pensions Article, Section 3-102, special appointment, temporary, contractual, supervisory, managerial and confidential employees are excluded from collective bargaining.  Additionally, certain executive branch agencies are exempt from collective bargaining and all positions in those agencies are excluded from collective bargaining.

Employees in this classification are eligible to receive overtime compensation.  An employee who works more than the normal workweek is entitled to be compensated for that overtime as provided by State Personnel and Pensions Article, Section 8-305.