12/14/2010 39010

MEDICAL RECORDS SUPERVISOR

DEFINITION:

This is technical and supervisory work in the operation of a medical records department in a state facility.

An employee in this job supervises, plans, organizes and performs the technical work of a medical records department where medical histories of all patients are established, classified, and maintained. Work involves maintaining and updating patient health records; reviewing the records for completeness and accuracy to ensure their applicability for patient treatment, research, and case study; regulating the release of medical information; and ensuring that all materials shared between state facilities and outside entities are relevant and appropriate according to applicable laws and regulations. Work also involves the supervision of specialized clerical staff engaged in medical records maintenance functions. Work is performed under the direction of an administrative supervisor and is reviewed for compliance to departmental and facility policies and procedures through reports, conferences, and inspections.

EXAMPLES OF WORK:

Ensures each patient has a separate and complete medical record.

Supervises and participates in the creation of new medical records for patients entering the system, reactivation of older medical records, and the merging of temporary medical records with the patient’s permanent file.

Reviews medical records for completeness and accuracy, referring inadequate or incomplete records to treatment staff for correction.

Codes or supervises the coding of diseases, operations, special therapies and program services, and treatments.

Regulates the release of information to appropriate departmental personnel and external requestors, to include healthcare providers, insurance companies, attorneys, and others.

Reviews medical records with patients upon request.

Interviews patients to identify past medical record history and ensures the completion of authorization forms to request information from previous healthcare providers.

Reviews, prepares, and monitors the transfer of medical records into and out of the facility by completing a transfer checklist, ensuring the medical record is complete, and locating missing information.

Supervises and participates in the indexing and cross-indexing of information contained in medical records.

Compiles pertinent medical information from records and creates abstracts to forward to authorized personnel.

Prepares or provides relevant medical information to be used in the compilation of statistical reports.

Presents or assists in the presentation of medical records information in court cases.

Oversees the facility’s medical records archiving process to include the preparation and transfer of medical records to the State Records Center.

Maintains knowledge of current laws and regulations governing the release or sharing of medical information.

Ensures the medical records department is operated in accordance with applicable departmental policies and procedures.

Provides information and advice to agency staff regarding medical records administration.

Supervises and participates in the filing, withdrawal, and issuance of medical charts and reports.

Provides direction to medical records students participating in an approved education or internship program.

Performs the full range of supervisory duties.

An employee in this job may participate in the performance of their subordinates’ work consistent with operational or organizational requirements.

Performs related work as required.

REQUIRED KNOWLEDGES, SKILLS, AND ABILITIES:

Knowledge of medical recordkeeping principles and practices.

Knowledge of medical terminology required for the proper classification and maintenance of medical records.

Knowledge of the medicolegal aspects relating to the maintenance and release of information from medical records.

Knowledge of statistical principles and techniques as they apply to medical records work.

Knowledge of the methods and techniques used to establish and maintain medical filing and recordkeeping systems.

Knowledge of the methods and techniques used in the coding and indexing of medical records.

Ability to establish and maintain effective working relationships.

Ability to communicate effectively in writing.

Ability to communicate effectively orally.

NECESSARY SPECIAL REQUIREMENT:

Possession of a valid Registered Health Information Technician (RHIT) certificate or a Registered Health Information Administrator (RHIA) certificate issued by the American Health Information Management Association (AHIMA), or eligibility for certification including completion of an AHIMA approved RHIT or RHIA Health Information Management education program.

POST EMPLOYMENT REQUIREMENT:

Employees who meet the Necessary Special Requirement based on the eligibility option for the RHIT or RHIA certification must obtain one of these certifications within 12 months of employment.