2110-Medical Records Clerk

Job description

INTRODUCTION

Under general supervision, abstracts medical raw data for statistical purposes and research; assists in the maintenance of medical records; and performs related duties as required.

DISTINGUISHING FEATURES

Positions in this class perform the most routine clerical tasks connected with the processing of medical records. Supervision is received from accredited Medical Record Technicians.

SUPERVISION EXERCISED

MAJOR, IMPORTANT, AND ESSENTIAL DUTIES

According to Civil Service Commission Rule 109, the duties specified below are representative of the range of duties assigned to this job code/class and are not intended to be an inclusive list.

1. Analyzes medical charts for completeness and codes diseases and operations for abstracts; abstracts medical record information for the Electronic Health Record input which is necessary for the production of medical statistical reports and for medical research purposes.

2. Ensures complete and accurate medical records by following up on inconsistencies and omissions with the appropriate personnel.

3. When assigned, prepares medical abstracts from patients' charts in response to inquiries from private physicians, hospitals, clinics, insurance companies, attorneys and other private and public medical agencies indicating results of laboratory tests, special tests, X-ray films, operations performed, diagnoses, pathological findings, and other pertinent information.

IMPORTANT AND ESSENTIAL KNOWLEDGES, SKILLS, AND ABILITIES

Knowledge of: Medical terminology and basic medical procedures and practices; modern office methods and procedures.

Ability and Skill to: Understand and follow complex oral and written instructions; maintain complex medical records and prepare reports from such records; establish and maintain effective working relationships with physicians, other employees, patients and the general public.

Requires sufficient skill in typing to timely complete work.

MINIMUM QUALIFICATIONS

These minimum qualifications establish the education, training, experience, special skills and/or license(s) which are required for employment in the classification. Please note, additional qualifications (i.e., special conditions) may apply to a particular position and will be stated on the exam/job announcement.

Education:

Experience:

One (1) year of experience, within the last five (5) years, performing one of the following duties: abstraction of medical information, coding, release of medical information or working in any healthcare setting dealing with medical records.

License and Certification:

Substitution:

One (1) year of clerical experience AND completion of a comparable Community College course indicated below from a Health Information Technology Program approved by the American Health Information Management Association (AHIMA): Introduction to Health Information Technology, Organization of Health Data, Medical Terminology and Legal Aspects of Health Records, may be substituted for the required experience; OR

Possession of a valid Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification may be substituted for the required experience.

SUPPLEMENTAL INFORMATION

PROMOTIVE LINES

2112 Medical Record Technician (accreditation as an Accredited Record Technician required)

ORIGINATION DATE:

2/18/75

AMENDED DATE: 11/09/2015

REASON FOR AMENDMENT To accurately reflect the current tasks, knowledge, skills and abilities defined in the most recent job analysis conducted for this job code.

BUSINESS UNIT(S): COMMN

Standard information

Disaster service work

All City and County of San Francisco employees are designated Disaster Service Workers through state and local law (California Government Code Section 3100-3109). Employment with the City requires the affirmation of a loyalty oath to this effect. Employees are required to complete all Disaster Service Worker-related training as assigned, and to return to work as ordered in the event of an emergency.

Historic and future compensation