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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 00196104 |
Description Activated On: 7/17/2026 8:31:42 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. This position is responsible for assisting in the initiation and maintenance of medical records by preparing and typing medical reports, abstracts, and summaries, and reviewing and processing medical records to insure their accuracy and completeness. |
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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. Compiles the Facility Census Report by coordinating reports from the Nursing Units and the Department of Social Services. Compiles statistical reports, which summerizes daily census statistics. Maintains Resident Information System by entering demographic data into datatbases. Produces scheduled and ad-hoc reports to meet the needs of fiscal and clinical services at Southeastern Veterans Center. Maintains individual medical records by organizing the record at admission, thinning the record of documents as they are no longer needed on a daily basis by the interdisciplinary team, retrieving all documents from the Living Area Record, the Medical Clinic, and Departmental Records, and integrating those documents with the Central Storage Record to produce a closed record at discharge. Audits active and closed medical records for timeliness and completion of documentation; displays variations from audit criteria for follow-up by individuals responsible for completion. Maintains system of issuing and maintaining Physician Encounter Sheets for Medicare Part B Physician Services; assigns diagnostic and procedure codes and assures an audit trail from the medical record through diagnostic/procedure coding processes. Tracks medical record documentation to provide information to the interdisciplinary team regarding "due dates" for specific medical record documents. Abstracts information from medical records to provide summary reports during residence an at discharge. Assists staff in the retrieval of medical records and the documents therein. Release clinical information to authorized staff, other health facilities, private practitioners, social agencies, and third parties while safeguarding the confidential nature of this information. Job functions are performed using alphabetical, numerical, and subject filing systems as they apply in a medial records department. Diagnostic and Procedure Coding functions utilizing ICD9 CM, CPT-4, and HCPCS coding systems. Both manual and computere generated systems are utilized to produce statistical reports. The incumbent in this position uses the typewriter, advanced word-processing, spreadsheet, and database functions. Performs work in accordance with the DMVA general safety rules and safety rules for this position. Immediately reports all workplace injuries or incidents to the supervisor; and/or immediately corrects any safety hazards in the work area or reports same to supervisor. |
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. Abstracts information from medical records to provide summary reports during residence an at discharge. Tracks medical record documentation to provide information to the interdisciplinary team regarding "due dates" for specific medical record documents. Audits active and closed medical records for timeliness and completion of documentation; displays variations from audit criteria for follow-up by individuals responsible for completion. |
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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. N/A 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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