Nature of Work
Under general supervision, performs supervisory work in the care and maintenance of all medical records in a hospital or health care facility. Work includes the development and maintenance of a classification system of medical records including quality control, collection of statistical data, and quantitative analysis of unit medical record activities. Supervises all technical records functions for the unit to insure compliance with federal, state and professional requirements. Work is performed under the general supervision of the Clinical Director or Hospital Administrator. In the the Department of Health and Human Resources, Bureau for Medical Services, performs administrative oversight of and complex technical assistance for all coding-related duties. Assures compliance with federal, State, and local regulations governing the coding-related duties of the Bureau for Medical Services. Uses independent judgement to determine appropriate action taken to achieve desired results. Has responsibility for providing consultation on highly complex individual problem situations. Performs related work as required.

Examples of Work
Supervises the daily record coding, posting and updating procedures and reviews medical records for completeness and accuracy and for compliance with federal, state and professional standards.
Insures the strict confidentiality of all patient's medical records; screens the release of information to all personnel.
Prepares various associated reports including monthly death reports, monthly statistical patient data reports and a comprehensive annual statistical report on admissions and releases.
Supervises file clerks in the routine maintenance and disposition of medical records which includes preparation of records for microfilming and storage of original records.
Trains new employees and may conduct continuous in-service training classes in medical terminology, coding procedures for medical records unit personnel.

Knowledge, Skills and Abilities
Knowledge of the principles and practices of medical records management.
Knowledge of the standards of the American Medical Records Association.
Knowledge of the coding system related psychiatric and medical diagnosis.
Knowledge of medical, psychiatric, and anatomical terminology.
Knowledge of the state and federal laws regulating the use and disclosure of medical records information.
Knowledge of office practices, procedures, and equipment.
Knowledge of hospital policies and procedures.
Ability to supervise a medical records unit and to establish and maintain effective working relationships with all levels of staff.
Ability to organize and prepare reports and summaries for oral and written presentation.
Ability to analyze and evaluate medical records to apply established standards, regulations and laws to specific problems.

Minimum Qualifications      [Top]
Training:
Accreditation as a Medical Record Technician (ART) by the American Medical Record Association.
Substitution:
Three years of experience involving filing, coding, and/or indexing medical records in a hospital or health related setting; one year of which must have been in a supervisory capacity may substitute for the required training.

Experience:
Two years of experience in a medical records unit working directly with patient's medical records.

Special Requirement for the Department of Health and Human Resources
Bureau for Medical Services:

Training:
Currently certified by the American Health Information Management Association (AHIMA) as a Certified Coding Specialist (CCS)or as a Current Procedural Coder for Physicians (CPC-P).

Experience:
Four years of full-time or equivalent part-time paid coding experience in a health care facility and/or physician's office.

Established: 7/16/92
Revised:      7/14/03
Effective:     7/14/03