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Medical Records Administrator

Salary: $26.67-$32.55 hourly / $4,638-$5,662 monthly / Range: 5916

DEFINITION: Under general direction, plans, oversees, and implements the Countywide medical records systems for the acute and ambulatory care services of the Alcohol, Drug & Mental Health Services (ADMHS) or Public Health Department; may supervise medical records staff; and performs related work as required.

DISTINGUISHING CHARACTERISTICS: This classification is distinguished by its responsibility for ensuring that medical records are maintained in accordance with applicable laws and regulations. It is distinguished from the Medical Records Technician by its responsibility for the overall administration and supervision of the medical records program.

EXAMPLES OF DUTIES:

1. Plans, organizes, and oversees medical record keeping for the Alcohol, Drug & Mental Health Services or Public Health Department; leads the formation of policies and procedures regarding content, processing, and confidentiality; participates in the development or evaluation of automated medical records and digital archiving systems; prepares summary reports from medical records for clinicians and management; for ADMHS formulates procedures related to the retention of medical records for acute and ambulatory care and records provided by managed care network providers.
2. Monitors medical records for compliance with Federal and State laws and regulations; ensures that medical records meet standards for reimbursement by third-party payers and for audits; responds to requests for release of confidential patient medical records in accordance with laws and regulations; and completes surveys of medical records requesting statistics and data related to medical records.
3. May plan, direct, and evaluate the work of the medical records staff; interviews and recommends staff to be hired; may counsel and discipline staff; trains new staff and updates staff on changes in regulations or policies; may enter, code, and prepare abstracts of medical information in absence of staff.
4. Prepares and conducts training sessions on medical records maintenance, processing, retention, and release for department clinicians and support staff, managed care network providers, and vendors such as transcription and copying services.
5. Determines vendor services needed for transcription and copying of records; monitors performance of contracted vendor services; and reviews costs of vendor services in accordance with contract.
6. Attends training to maintain credential as a Registered Health Information Administrator or Registered Health Information Technician; and attends staff meetings as required.

EMPLOYMENT STANDARDS:

1. One year of experience in overseeing medical record systems for acute and/or ambulatory services as a Registered Health Information Administrator; and a current Registered Health Information Administrator credential issued by the American Health Information Management Association; or,
2. three years of experience overseeing medical record systems for acute and/or ambulatory services as a Registered Health Information Technician; and a current Registered Health Information Technician credential issued by the American Health Information Management Association.

Additional Qualifications: Possession of a valid California Class C Driver's License.

Knowledge of: principles and practices of medical record keeping for acute and ambulatory care services; medical terminology; federal and state laws and regulations related to medical records content, privacy, release, and retention; International Classification of Diseases (ICD9) system and Current Practices and Trends (CPT) to code medical diagnoses; basic math to compute summary statistics of medical records and to prepare and monitor program budget.

Ability to: plan, direct, and evaluate the work of staff; read and interpret laws, regulations and procedures related to medical records content, processing, confidentiality and retention; prepare correspondence related to the release of medical records and reports using correct grammar, punctuation and spelling; prepare and give training sessions before small groups; establish and maintain effective working relationships with others including legal staff, professional staff, and community and regional peers; maintain confidentiality of patient records; and use personal computer applications such as word processing and spreadsheets.

Desirable Qualifications: (For the Alcohol, Drug & Mental Health Services Department)

Knowledge of: terminology and nomenclature related to Diagnostic System Management for mental health diagnoses (DSM-IV); state laws and regulations related to acute mental health records and the release of mentally ill patient records; and automated medical record information and archiving systems.
 



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