This title is in the unclassified service and in the SUNY Professional Services Negotiating Unit.
Medical Records family description: Support the delivery of health care by developing, organizing, implementing and maintaining health information systems for accurate storage and retrieval of medical information in accordance with the standards of the institution, accrediting and regulating agencies.
Primary responsibility for assigned subfunctions within Medical Records (i.e. correspondence, file room, the evening operation, quality assurance, coding division, DRG operation, data gathering); coordinates the implementation of a unit's internal quality assurance program, and assists with the planning and development of records retention, preservation and retrieval systems in accordance with the institutional standards and regulatory agency standards. Based upon assigned areas, the assistants may supervise and be responsible for the following duties and responsibilities as they relate to the assigned are: supervises data gathering and documenting data reliability; assists healthcare practitioners to develop meaningful evaluation systems, designs worksheets, screens medical records using established criteria, presents "deficient" cases, obtains statistical information for data displays and provides staff with model guideline and teaches audit techniques. Determines the incidence of various relevant review topics for the use of committees and individuals; supervises the screening of medical records for compliance with established criteria, designating exceptions or equivalents. Provides technical expertise to audit surveyors, and assists in the preparation of all surveys; participates in the selection and designing of all forms; ensures ongoing surveillance of practice indicators or monitors for medical staff review, retrieves criteria sets and data, conducts studies, evaluates results and insures the completion of each audit. Evaluates methods for improving primary source data to facilitate data retrieval analysis, tabulation and display; evaluates regulatory requirements to insure hospital compliance and designs formats to aid in reviews. Reviews performance against accepted standards and educates various groups on audit methodology; assists in developing standards to assure confidentiality of patients' and physicians' records and alerts the departments, the Quality Assurance Coordinator and Director of Medical Records of all bonafide record documentation deficiencies identified. Participates in the department's quality assurance program; develops criteria, abstracts data, displays deficiency trends and trains staff in techniques; supervises the processing of laboratory reports and ensures the collation of such reports within the medical records, and maintains statistics as to volume and status on all laboratory reports from nursing and the clinic area. May be responsible for developing and implementing the Concurrent Chart Program; assists in determining appropriate methodology and standard classification and indexing best suited to the hospital's needs, developing, promulgating and revising department record goals, procedures and guidelines. Assists in maintaining record confidentiality and availability; supervises the collection, quantitative analysis, coding maintenance and retrieval of the hospital's medical records, transcription of reports and incomplete charts linked to a suspension program; participates in related hospital committees as assigned. Participates in in-service training courses holding orientation meetings and lecturing on various aspects of Medical Records Administration; attends professional association activities and assists in the quality testing of approved hospital forms as they relate to program goals and regulatory standards. Supervises the subordinate staff.
BS in Medical Records, RRA certification. Three years of experience to include one year in a supervisory/ administrative capacity. Master's Degree in related field.
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