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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00047665 |
Description Activated On: 4/23/2025 11:14:50 AM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. The employee in this position is responsible and accountable for directing the Medical Records Department. Employee establishes and maintains active/inactive medical records whether in paper for electronic format. The employee develops and implements policies and procedures required to ensure medical records are in compliance with accredittion, certification and licensure requirements. This individual reports directly to the Performance Improvement Director. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. Working time percentages are approximate and can change daily based on operational needs. 20% •Directs Medical Record Assistants in the daily operations of the Medical Records Department •Performs interviews for prospective Medical Records Assistants. •Supervises a staff of clerical/technical employees. Provides Medical Records Assistant orientation training and oversight with assistance of Medical Records Department of all new hire Medical Records employees •Prepares and revises job descriptions and completes performance evaluations on subordinate employees. •Ensures that all subordinate staff receives all mandatory training and that identified training needs are being met. •Conducts departmental meetings with staff as necessary. 20% •Reviews Medical Records for completeness and accuracy and refers incomplete or inaccurate records to attending physicians and/or Medical Director for correction; obtains necessary signatures, laboratory and x-ray reports, electrocardiographic tracings, necropsy, pathology, and all other reports, and ensures the electronic medical record is complete as the records relate to medical- legal documentation issues in conjunction with Quality Assurance/Performance Improvement. •Continuously monitors regulatory requirements for changes that affect maintenance of clinical records. 10% •Acts as the Center’s Privacy Officer as required in the Health Insurance Portability Act of 1996. Develops policies/procedures to assure compliance with the Act. Develops, conducts, and provides oversight on training on the HIPAA Act with all employees. •Oversees the release of information to authorized persons by following established policies to maintain confidentiality. •Supervises the release of information to physicians, representatives of insurance companies and others who have a legitimate interest in case histories. •Extracts information from medical records for researchers and physicians for use in projects or staff conferences. 10% •Codes or verifies coding of diseases, operations, special therapies and program services and treatments with diagnostic related group assignment according to standard nomenclature and classification systems. •Searches medical records to make abstracts of pertinent information; forwards abstracts to authorized personnel. 10% •Provides assistance in Utilization Management Review, Licensure, Medicare/Medicaid Certification Surveys and others as assigned. •Conducts continuous review of policies, procedures, budget, and personnel actions necessary to operate the Medical Records Department and ensure adequate functioning of the facility’s electronic health record. •Provide technical advice with applications of Electronic Health Record changes and updates to the facility administrator and I.T. department as requested. 10% •Prepares or supervises the preparation of periodic reports on such subjects as diagnosis, prognosis, morbidity, mortality and birth; utilization of facility beds according to professional services, and other reports particular to the needs of the facility via the facility’s electronic health record and other resources. •Conducts a continuous review of the facility’s policies related to medical records, including HIPAA, and develops new or revised policies to ensure compliance with State and Federal Regulations. 5% •Develops, maintains, and provides training to all facility staff; new hire, annually, and as required, in confidentiality, privacy regulations, and other areas as assigned. •Instructs employees in indexing and filing methods, preparation and arrangement of medical information, medical terminology and the nomenclature and classification of diseases; instructs facility staff in nomenclature, classification of diseases, treatments and program services and use of medical records. •Serves, participates, and supports committees by providing professional and technical advice in all areas under the scope of Medial Records to maintain the overall mission of the Center. 5% •Supervises and participates in the work of filing, withdrawing, and issuing records and files to authorized personnel. •Supervises and participates in indexing and cross-indexing information contained in medical records. 5% •Provides statistical and medical data information to comply with established reporting requirements and those requested for all other reasons as required. 5% •Maintains current departmental procedure manuals by incorporating changes as they occur and conducting an annual review to provide guidance to staff on all functions and tasks within the Medical Records Department. •Presents medical records in court cases involving subpoena/extra Order of the Court of facility medical records. •Serves as a consultant on medical records administration to other state facilities. •Performs all other related work as required. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. Assigns and prioritizes medical records staffs assignments. Approves release of medical information on routine requests refers complex legal/nonroutine requests to CEO/legal advisors. Maintains essential work functions and makes decisions on leave approvals accordingly. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Licenses, registrations, or certifications: 1. Medical Records Technician Accreditation from the American Health Information Management Association 2. N/A 3. N/A 4. 5. 6. |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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