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MEDICAL RECORDS TECHNICIAN (CODER)
This position is located in the Nursing Department of the Kayenta
Health Center, Kayenta, Arizona. The purpose of this position is
to perform outpatient chart analysis, coding, and a variety of
support services of Medical Record functions for the Health Center
and Inscription House Health Clinic.
II. MAJOR DUTIES AND RESPONSIBILITIES:
80% Analyzes all medical records to determine the completeness
of records in compliance with procedural requirement; presence
of all necessary reports, forms, and appropriate signatures, enumeration
and substantiation all diagnosis, treatment, and therapy, use of
standard nomenclature and compliance with adjudication requirements
for health care or research facility accrediting rating.
Analyzes the consistency of records that includes references to
several diseases, and various medical, diagnostic, therapeutic
and surgical procedures. Identifies inconsistencies or discrepancies
among medical documentation and discusses with appropriate staff
member. Codes medical records by determining and sequencing codes
to reflect the resources used in the care of patients.
Maintains the confidentiality and security of all medical records
in accordance with the Privacy Act, J C A H O, and I H S policies
and procedures. Monitor and records discrepancies from P C C record
review and returns forms to providers for correction.
10% Compiles and retrieves medical records data for audits, performance
improvement studies, research, patient care evaluation activities,
reports, and Health Center compliance.
5% Updates superbills annually, incorporating changes in I C D
-9-C M, C P T, and H C P C S codes. Orients staff to changes.
5% Provides consultation to Department heads and K H C Leadership
Team regarding coding and compliance issues. Works with K H C coding
staff to improve coding accuracy through periodic coding audits,
chart reviews, and training. Collaborates with the Business Office
and other departments to improve billing and collection, documentation
and other processes throughout all Kayenta Health Center facilities.
Performs other related duties as assigned.
Factor 1 – Knowledge required by the Position:
Knowledge of medical terminology and usage’s, covering the
full range of general medical, surgical, pharmaceutical, medical
abstracts, and abbreviations.
Practical knowledge of well-established medical records procedures,
regulations, and principles to carry out a variety of medical records
functions such as analysis, coding, quality assurance, and compiling
Knowledge of physiology, major anatomical systems, and related
Knowledge of a broad range of medical records references and regulatory
requirements for medical records.
Knowledge of classification systems to code diagnostic and operative/procedural
information using various classification methods. Knowledge of
I C D - 9 - C M, C P T -4, H C P C S, coding nomenclature and Medicare
Knowledge of medical records confidentiality and security, for
example, Privacy Act of 1994, Release of Medical Information and
Freedom of Information Act.
Knowledge and skill of inter-departmental communications.
Skill to collect and organize data for statistical reports.
Factor 2 – Supervisory Controls:
Incumbent is under the general supervision of the Director of
Nurses. Supervisor makes assignments by defining the overall goals
and priorities of the work and helps the incumbent with unusual
situations that do not have clear precedents. Incumbent plans and
carries out assignments, and handles problems and deviations in
the work assignments using established policies, instructions,
and accepted practices in medical records management. The supervisor
places considerable reliance upon the incumbent’s knowledge
of medical records. Work is reviewed for results achieved, technical
soundness, and conformity to medical record policy and requirements.
Factor 3 – Guidelines:
Well-established procedures for doing the work and other specific
guidelines are available including a variety of written medical
records reference and regulatory requirements. Such guidelines
include but not limited to the following: I H S Manuals, Privacy
Act of 1974, Patient Care Component manual, Department Policy & Procedure
Manuals, Medical Dictionaries, coding manuals etc. The work situation
requires the employee to use judgment to identify and select the
most appropriate guidelines, reference, and procedure for application
in making minor deviations to adapt such guidelines to specific
cases. Incumbent refers situations to which existing guidelines
are not applicable to the supervisor.
Factor 4 – Complexity:
Work includes the performance of different and varied medical
record processes and methods. Incumbent performs periodic reviews
of the work and that of other employees in compliance with the
regulatory requirements. Decisions about what needs to be done
require the incumbent to determine the relevance of many facts
and conditions such as information within the record, legal and
regulatory requirements, and other variables. The chosen course
of action may have to be selected from many alternatives. The work
involves analyzing and interpreting conditions and elements to
correct complicated inconsistencies or discrepancies in the records.
Factor 5 – Scope and Effect:
The work involves performance of assignments according to specific
rules or procedures. Incumbent analyzes medical records information
to ensure compliance with procedural requirements, codes diseases
and operations, and compiles other medical information. The work
affects the accuracy, timeliness, reliability, and acceptability
of information in the medical record.
Factor 6 – Personal Contacts:
Contacts are with co-workers, medical staff, community, and other
staff in the health care facility and other outside medical facilities.
Factor 7 – Purpose of Contact:
To coordinate work efforts and solve technical problems.
Factor 8 – Physical Demands:
Work is primarily sedentary. Incumbent sits comfortably to do
the work. However, there may be some walking, standing, or carrying
of light items such as manuals and files. The work does not require
special physical demands.
Factor 9 – Work Environment:
The work environment involves everyday risks or discomforts that
require normal safety precautions typical of such places as medical
facility offices. There is adequate light, heat, and ventilation
in the work area. Incumbent maybe required to work evenings, nights,