Under general supervision, supervises and performs the more advanced coding of disease and medical procedures using the standard classification system; and does related or other work in accordance with Rule 3, Section 3 of the Civil Service Rules.
CLASS CHARACTERISTICS
This is the supervisory level class in the Medical Records Technician series. An employee of this class supervises and trains employees working in the coding area of the Medical Records Division. The incumbent is responsible for auditing and evaluating the work of the Medical Records I and II's. The incumbent may assist in the coding of the most complex inpatient as well as outpatient medical information. An incumbent may also supervise the clerical staff of a division responsible for the maintenance of a large collection of medical and/or psychiatric case histories.
TYPICAL DUTIES
Interviews, selects, and supervises subordinate personnel; evaluates work performance; provides training to department and other hospital staff.
Analyzes medical charts for comparison against clinical indicators; identifies deviations from indicators; may prepare reports for presentation to the medical staff and administration.
May perform the most complex coding of diseases and medical procedures using the standard classification system.
May maintain statistical and computerized reports and indexes on health data; research same to locate health data, information requested by physicians, health care accrediting agencies, and others.
Screens requests for release of medical information from medical records; gives out authorized information to physicians, hospital personnel, attorneys, insurance companies, and others; accepts and responds to court subpoenas; may appear in court to give testimony on medical records.
May provide direction, answer questions, and resolve problems of clerical staff of a medical records division of San Joaquin County Health Care Services.
MINIMUM QUALIFICATIONS
Licenses & Certificates: Possession of a Registered Health Information Technician Certificate issued by the American Health Information Management Association.
Substitution: Completion of an approved program for Registered Health Information Technician may substitute for the required certification. Employees must obtain certification as an Registered Health Information Technician (RHIT) within one year of completion of the program.
AND EITHER I
Experience: One-year equivalent to a Medical Records Technician II in San Joaquin County.
OR II
Experience: One year of journey level experience in an acute care hospital, mental health inpatient facility, skilled nursing facility, or large group-practice/medical clinic, coding diseases and operations using the standard classification system, at least six months of which must have been in a lead or supervisory capacity.
KNOWLEDGE
Medical record keeping principles and practices, including familiarity with standard nomenclature and classification; functions of a medical records administration; nature and uses of medical record charts; the business and professional relationships and ethics involved among hospital physicians and patients; principles of staff planning; principles of effective supervision.
ABILITY
Plan, assign, and supervise specialized and routine work; prepare reports based on information derived from medical records; utilize a variety of office procedures and equipment; make independent decisions in procedural matters; establish and maintain effective working relationships with other employees, physicians, and the general public; communicate effectively, both orally and in writing.
PHYSICAL/MENTAL REQUIREMENTS
Mobility-Frequent operation of a data entry device, repetitive motion, sitting for long periods, walking; occasional standing, pushing, pulling, bending, squatting, climbing; Lifting-Frequently 5 pounds or less; occasionally 5 to 30 pounds; Visual-Constant good overall vision and reading/close-up work; frequent color perception and use of eye/hand coordination; occasional use of depth perception and peripheral vision; Hearing/Talking-Frequent hearing of normal speech, hearing/talking on the telephone, talking in person; Emotional/Psychological-Frequent decision making, and concentration; Special Requirements-Some assignments may require working weekends, nights, and/or occasional overtime; Environmental-Occasional exposure to varied weather conditions.
San Joaquin County complies with the Americans with Disabilities Act (ADA) and, upon request, will consider reasonable accommodations to enable individuals with disabilities to perform essential job functions.
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