MEDICAL RECORDS ASSISTANT - 09082026-80674

Overview

Under general supervision, is responsible for medical records clerical duties of average difficulty in the maintenance and coding of medical records; and performs related work as required. An employee in this class is responsible for maintaining medical records, reports, and hospital statistics. Work may involve assisting others in routine coding of diseases and filing of information. This class differs from Medical Records Technician 1 in that an incumbent of the latter is certified as a Registered Health Information Technician (RHIT) and may assist in or supervise the operation of a hospital medical records library.

Responsibilities

• Maintains medical records securely to ensure confidentiality of information contained in records.
• Researches patient records and legal documents to determine requested information may be released to requesting party.
• Explains Health Insurance and Accountability Act (HIPAA) and other laws, rules, procedures to individuals requesting information contained in medical records.
• Verifies information to be placed in patient records to ensure accuracy and completeness.
• Resolves codes or diagnoses with conflicting, missing, or unclear information.
• Communicates in person, email, or other communications to exchange information with hospitals, physicians, funeral directors, survey teams, auditors, the general public, and local, state, and federal agencies.
• Collects patient information to create reports. Compares statistical data across various records and computes statistical data for monthly reports.
• May type medical transcription from database or other sources concerning patient evaluation, treatment, and other matters as dictated by physicians and/or other health professionals.
• May lead and give guidance and training to less experienced workers in the coding and/or classifying of medical and demographic data on vital records or health statistics.

Qualifications

Education and Experience: Education equivalent to graduation from a standard high school and experience equivalent to four years of increasingly responsible full-time clerical work, including at least one year of experience in medical records filing work, in a vital records or health statistics medical coding and classification unit, or in a similar medical setting.

Substitution of Experience for Education: Qualifying full-time clerical experience may substitute for the required education on a year-for-year basis.

Competencies (KSA's)

Competencies: Instills Trust, Customer Focus, Communicates Effectively, Decision Quality, Interpersonal Savvy

Knowledge: Customer and Personal Service, Clerical, Communications and Media, Law and Government, Medical Record Management

Skills: Active Learning and Listening, Speaking, Writing, Basic Typing

Abilities: Information Ordering, Written Comprehension, Speech Clarity, Limb and/or Full Body Coordination, Selective Attention

Tools & Equipment

• Computer
• Telephone
• Printer/Copier/Fax Machine
• Step Stool or Ladder