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MEDICAL RECORDS TECHNICIAN (CODER)
G S-675-06

I. INTRODUCTION:
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 data.

Knowledge of physiology, major anatomical systems, and related disease processes.

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 Compliance Regulations.

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, and holidays.