JOB TITLE: MEDICAL RECORDS ASSISTANT

JOB CODE: 39000

DEFINITION: This is specialized clerical work in the creation, maintenance, classification, review, and abstraction of medical records in a Commonwealth facility.

An employee in this job assembles, maintains, classifies, transmits, and reviews medical records. Work involves labeling, filing, charting, copying, and purging medical documents; preparing abstracts and transcribing medical information; performing coding and indexing of medical information, such as medical diagnoses, medical services rendered, and medical procedures, in accordance with the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding and guidelines; completing forms; and collecting, organizing, verifying, and entering data. Work is performed under general supervision and is reviewed for adherence to established policies and procedures through conferences, reports, and inspection of results.

EXAMPLES OF WORK: (NOTE: The examples of work are representative of the work, but every position classified to this job may not perform all examples of work listed. Conversely, this is not an all-inclusive list of work examples.)

• Creates, labels, files, charts, organizes, purges, copies, scans, reports, and extracts and securely transmits medical documents to authorized individuals in accordance with applicable laws, rules, and regulations.

• Reviews medical records to ensure all required documentation is present and completed in a timely manner; conducts discharge analysis and chart closure upon the death or discharge of individuals served.

• Prepares abstracts and transcribes dictated, recorded, and written medical information onto forms or into templates.

• Abstracts medical records by reviewing documentation to determine its completeness, accuracy, and suitability to support insurance reimbursement billing, such as for Medicare Part B.

• Codes, indexes, and cross-indexes medical diagnoses, medical services rendered, and medical procedures in accordance with official guidelines for coding and reporting.

• Drafts routine requests for medical information from other facilities, hospitals, agencies, or individuals; and compiles responses.

• Prepares and transfers medical records for individuals’ continuity of care.

• Assists in gathering and compiling statistical data utilized to develop reports, facility censuses, and discharge analyses.

• Collects, compiles, tracks, organizes, verifies, compares, and enters data into databases and spreadsheets regarding individuals served and services rendered.

• Conducts chart reviews to ensure required documents are updated, maintained, and purged in accordance with applicable directives, policies, and procedures.

• Accesses, uses, and discloses all medical information and documentation in compliance with Personally Identifiable Information (PII) and Protected Health Information (PHI) policies and regulations.

• Collects and enters all pre-admission information.

• Records medical information on death certificates.

• Performs related work as required.

ENTRY LEVEL KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of the laws, regulations, policies, and procedures for accessing, using, and disclosing private, sensitive, legally-privileged, and confidential information.

• Knowledge of the medical nomenclature, medical classification systems, and official medical coding requirements necessary for classification and coding of medical records.

• Knowledge of medical record-keeping methods and techniques.

• Knowledge of standard medical vocabulary and usage, spelling, grammar, and punctuation.

• Knowledge of the use and functionality of Microsoft Office Suite software.

• Ability to transcribe dictated, recorded, abstracted, and written medical information.

• Ability to sort, file, and cross-index electronic and paper medical records.

• Ability to communicate effectively orally.

• Ability to communicate effectively in writing.

• Ability to establish and maintain effective working relationships.

MINIMUM EXPERIENCE AND TRAINING: (NOTE: Based on the Entry Level Knowledges, Skills, and Abilities)

• One year of clerical experience maintaining or reviewing medical records, transcribing dictated or recorded medical information, or conducting medical abstracting and coding;

or

• Graduation from an accredited medical secretarial, medical records, medical transcription, medical assisting, medical coding, or health information management program;

or

• An equivalent combination of experience and training.