|Step 1||Step 10||Step 2||Step 3||Step 4||Step 5||Step 6||Step 7||Step 8||Step 9|
|Salary Range 15||$2202||$3195||$2289||$2361||$2461||$2558||$2672||$2786||$2912||$3048|
GENERAL DESCRIPTION OF CLASS
The MEDICAL RECORD SPECIALIST reviews, abstracts, and codes diagnosis and treatment information from short stay and inpatient medical records for the purpose of providing patient information for appropriate billing of health care services, as input to research on specialized health care subjects, for registration with national and state registries, to provide data for research and to ensure hospital compliance with Federal, State, and Joint Commission on Accreditation of Hospitals and the American College of Surgeons regulations and guidelines.
This is a single classification and not currently part of a series of classes.
DUTIES AND RESPONSIBILITIES
The duties listed below are not inclusive but characteristic of the type and level of work associated with this class. Individual positions may perform all or some combination of the duties listed below as well as other related duties.
RELATIONSHIPS WITH OTHERS
Employees in this class have daily in person, written, and telephone contact with physicians, hospital cancer registries and other medical and agency personnel to obtain, clarify, and exchange information. Requests for diagnosis and treatment codes from other sections in the agency are received by telephone throughout the day. Review of medical records with physicians often requires patience and diplomacy to resolve problems or disagreements on coding.
Employees in this class receive general supervision from an administrative superior. Work is reviewed for accuracy, completeness, and adherence to medical record regulations and guidelines, through regular meetings, and ongoing quality management studies. The Oregon Medical Professional Review Organization routinely reviews medical records for accuracy of coding and DRG assignment. Federal and State agencies may spot-check medical records for accuracy of coding, DRG assignments, and hospital compliance with JCAH guidelines and Federal and State laws. The American College of Surgeons Cancer Program Manual provides standards and operational guidelines.
The Joint Commission on the Accreditation of health care organizations provides regulations and guidelines for the establishment and maintenance of complete medical records. Federal laws and guidelines apply to confidentiality of medical records, record keeping, and reimbursement requirements for the Medicare benefit system. State laws, Administrative Rules, and agency policies and procedures provide guidelines for confidentiality of medical records, retention of records, reporting of specific medical statistics, and completion of work. Medical dictionaries, textbooks and the International Classification of Disease, Ninth Edition, Clinical Modification drug formularies, the American Medical Association current Procedure Terminology, SEER Cancer Staging manual provide reference information and guidelines for appropriate codes for diagnosis and cancer staging.
Positions in this class are primarily found in hospitals and health institutions. They require the willingness to work in the environment associated with the position's location and purpose and to work for long periods at a work station, reading a computer terminal screen, in an environment including the noise and temperature variations necessary for computer equipment, and to work overtime.
NOTE: Some positions require certification by the American Medical Record Association as an Accredited Record Technician or be eligible to take the qualifying examination at the time of appointment.