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T.H. Medical Records Specialist (SL2)

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.

• Supervises and participates in the conduct of interim reviews to confirm billing, computer entry and data quality;
• reviews codes and analyzes the medical records to ensure compliance with fiscal and regulatory requirements;
• provides in-service training as a routine function to staff directly and indirectly involved in the coding unit which includes other health related practitioners whose knowledge of coding is critical to the financial well-being of the facility;
• coordinates activities between department supervisory staff, Business Office and Utilization Review Department.
• May participate in concurrent diagnostic and operative coding verification and works with the DRG Coordinator as it directly relates to the coding of medical records;
• prepares and maintains medical records for the purpose of diagnostic and operative medical coding;
• ensures the selection of accurate and descriptive codes from the appropriate classification system;
• accurately classifies conditions and illnesses.
• Determines standard nomenclature for classification systems;
• assures retrievability and generally assists in meeting regulatory requirements;
• determines the order of primary, secondary, and tertiary diagnosis to assist Accounts Receivable.
• Insures efficient and timely billing procedures;
• assists in the retrieval of billing documentation;
• completes necessary data for billing area and assures timely preparation of insurance requirements;
• ensures the completion of source documents for computer entry and collates files of previous admissions to verify systemic disease;
• determines which of the several classification systems should be used or how the classification system should be modified to meet particular needs to facilitate the identification of disease/ surgical/ therapeutic procedures.
• Analyzes medical records to ensure that the most suitable code is used;
• directly enters codes on the proper source documents, abstracts data;
• collates files of previous visits if needed and prepares charts foe reviewers, studies and audits, and prepares charts as requested.
• Maintains timely Diagnostic and Operative Indices;
• maintains optimal standards for coding;
• assures uniformity of coding;
• implements hospital specific codes and discusses "problem" charts and issues within the department with the proper authority.
• Assists in developing and implementing policies and in training staff on procedures and policies consistent with state-of-the-art coding principles and guidelines and maintains updated policies and procedures.
• Provides hands-on assistance regarding the outpatient, ambulatory, concurrent and interim coding needs of the hospital.
• Ensures the confidentiality of data contained in the patient's medical record as discussed in the institution;
• supports and promotes the Medical Record Department by participating in special projects.

Preferred Qualifications:

BS in Medical Records. RRA eligible, ART or CRT (Cancer Registry) enrolled in ART correspondence course plus two to four years of experience within the medical record field plus one year in a supervisory/ administrative capacity.

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