Human Resources

Medical Records Technician

DISTINGUISHING FEATURES OF THE CLASS:  This is a specialized, technical, supervisory position involving responsibility for assembly, coding, maintenance and retrieval of the assembly, maintenance and retrieval of resident medical records.  The work involves arrangement of medical information based on recognized nomenclature and classification of diseases.  Work is performed under the general supervision of the facility administrator with considerable leeway allowed for exercising independent judgment.  Supervision of clerical personnel may be assigned to the incumbent in this position.  Does related work, as required.

TYPICAL WORK ACTIVITIES:
Codes, cross-indexes and verifies diseases, and special therapy according to established nomenclature and classification systems;
Prepares periodic and statistical reports such as cost reporting for reimbursement, statistical analyses of facility bed utilization, out-patient and therapy services rendered, diseases treated, and other related records;
Selects and compiles medical data for use in preparation of special registers, indexes, analyses and reports;
Retrieves, abstracts, selects, tabulates and prepares data from resident charts in appropriate form as requested by authorized personnel;
Reviews records to insure completeness, compliance with procedural requirements, use of accepted nomenclature;
Requisitions supplies and equipment for the medical records department;
Participates in the operation of computer, related to medical records processing;
May take medical records to court in response to subpoenas;
Assists facility staff in complying with state and federal health codes, in preparing data for QA, care planning, survey process, and systems pertaining to the reimbursement process;
Reviews records to assure that the Nursing Home is in compliance with regulations concerning the medical record and that record retention is in compliance with regulatory agencies as well as facility policies;
Trains student interns from area colleges.
The above examples of duties are intended only as illustrations of the various types of work performed.  The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment of the position.

FULL PERFORMANCE KNOWLEDGE, SKILLS, ABILITIES AND/OR PERSONAL CHARACTERISTICS:  Good knowledge of the design and operation of medical records retention and retrieval systems; good knowledge of the appropriate content of medical records and the origins of clinical information; good knowledge of medical terminology and standard nomenclature for coding and indexing diseases; good knowledge of medical recordkeeping procedures; good knowledge of current trends in health care delivery systems; working knowledge of laws, regulations and techniques governing the maintenance and release of medical records; working knowledge of terminology of human anatomy and physiology; ability to maintain a variety of medical records accurately and neatly; ability to make routine arithmetic computations rapidly and accurately; ability to abstract medical records and related health care data; ability to plan and supervise the work of others.

MINIMUM QUALIFICATIONS:  Graduation from high school or possession of an appropriate equivalency diploma recognized by the NYS Department of Education, AND:

Graduation from a regionally accredited or New York State registered two year college with an Associate degree, or equivalent, in Medical Records Technology or closely related field.

*The term "patient" should be changed to "resident" when position is used in health related facilities.