Under general supervision, 2112 Medical Records Technician assists in analyzing, coding, and compiling all medical records on patients treated at City and County medical facilities; may assist the medical staff in the selection of cases for specific research projects; supervises clerical staff assigned to the Medical Records Department.
Examples of essential duties of this position include, but are not limited to:
- Assists in training and mentoring of assigned clerical personnel; monitors and leads medical records clerks/ clerical personnel by medical records clerical needs, making periodic reviews of the quality and quantity of work performed; assists in workflow development; assists in developing production standards to meet departmental goals; conducts in-service training.
- Serves as a liaison with medical health care providers, managers, and requestors by communicating medical records information in a timely manner; providing orientation and/or responses to medical record functions, procedures, and responsibilities; attending meetings as needed; resolving problems as encountered and promoting understanding and cooperation with medical record users.
- Analyzes medical record deficiencies in accordance with Information Management Standards mandated by JCAHO/Title 22 by scanning the records for appropriate signatures, medical entries, inclusion of proper forms and reports, and special audit requests to ensure a complete and concise legal document, timely assignment, and tracking of physician documentation deficiencies.
- Manages complex eFaxes workflow.
- Codes diseases and medical operations using an encoder and required EHR by using ICD-10-CM, ICD-10-PCS, and CPT as required by the Center for MediCare and MediCaid Services, American Medical Association, State of California, the Joint Commission on the Accreditation of Hospitals Organization, and Title 22 Standards in order to provide information for billing, data, research and retrieval of patients’ records by diagnosis and procedures performed.
- Processes medical records of patients by assembling, analyzing, coding, and checking for compliance with established policy on nomenclature and procedures; files charts and assists in the revision of files.
- Abstracts information from medical records for statistical indexing and for the preparation of summary reports to official agencies requesting medical information on patients.
- Assists medical staff in compiling data for research projects.
- When required, prepares hospital records to be taken to court and assumes responsibility for the return of such records to their proper place.
- Consults with doctors, nurses, and other personnel in order to issue complete, up-to-date, and accurate medical records.
- The 2112 Medical Records Technician may perform other duties as required/assigned.
In addition to the general 2112 duties described above, the link below outline specific responsibilities for positions included in this recruitment.