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T.H. Medical Records Senior Specialist (SL3)

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.

• Has specialized knowledge in the areas of coding medical legal correspondence, chart incompletion, terminal digit record keeping;
• supervises data gathering and documents the reliability of data produced at all levels, works with the Quality Assurance Coordinator and health care practitioners in the development of a meaningful evaluation system;
• selects and designs worksheets;
• screens medical records using established criteria;
• presents "deficient" cases, obtains statistical information for data displays;
• provides staff with "model" guidelines and teaching audit techniques to staff.
• Assists in screening medical records for compliance with established criteria and helps designate exceptions or equivalents;
• assists the Quality Assurance Coordinator in providing technical expertise to audit surveyors;
• participates in the preparation of surveys and by preparing written guidelines that can be followed by "non-audit" trained individuals;
• participates in the selection and design of all forms used with the medical record for data display.
• Evaluates methods for improving primary source data to facilitate data retrieval, analysis, tabulation and display, to structure a Quality Assurance Program meeting the agency requirements and needs.
• Evaluates regulatory requirements to insure hospital compliance, designs formats that will aid the committee reviews and performance against accepted standards and educates administration, clinical and student groups on Quality Assurance methodology.
• Provides hands-on assistance and supervision to the Incomplete Chart Review, Qualitative Analysis, Transcription and Forms Unit, and is responsible for data accuracy and computerization of unit reviews.
• Directs the flow of medical records and is responsible for maintaining the accuracy and reliability of retrieved data, also insures that records are in compliance with regulatory requirements;
• coordinates activities with other departmental staff, the Business Office, Utilization Review Department, Health Care Practitioners and Administrators as they relate to the Incomplete Chart Review, Qualitative Analysis, Transcription and Forms Unit.
• Maintains the computerization files of the units and seeks ways to improve chart flow;
• maintains timely listings of incomplete and delinquent records;
• provides productivity reports and monitors the efficiency of the unit.
• Participates in the department's in-service education programs;
• provides in-service training as a routine function to staff directly and indirectly in the Incomplete Chart Unit, Qualitative Analysis, Transcription Forms, or Concurrent Review Section, including other health care related practitioners whose knowledge of charting requirements is critical to the financial well-being of the facility.
• Assists in developing and implementing and maintenance of policies and trains staff on procedures and policies consistent with state-of-the-art charting requirements;
• maintains the confidentiality of information contained in the patients' charts, insures against any unauthorized disclosures.
• Supports and promotes the department by participating in other assigned duties;
• provides direct hands-on assistance in administering the hospital's Concurrent DRG Program;
• assists in physician assignment review and completion actions;
• directs staff to the appropriate departments/services.

Preferred Qualifications:

BS in Medical Records, RRA certification. Four to six years experience with two years in a supervisory/ administrative capacity.

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