2112-Medical Record Technician

Job description

CITY AND COUNTY OF SAN FRANCISCO

DEPARTMENT OF HUMAN RESOURCES

Title: MEDICAL RECORD TECHNICIAN

Job Code: 2112

INTRODUCTION

Under general supervision, 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; and performs related duties as required.

DISTINGUISHING FEATURES

The class of Medical Record Technician is characterized chiefly by the requirement for possession of a certificate as a Registered Health Information Technician (RHIT). Positions in this class are responsible for the performance of technical duties in the processing of medical records and for the supervision of Medical Record Clerks. Supervision is received from Medical Record Technician Supervisors who possess registration as a Registered Health Information Administrator (RHIA).

SUPERVISION EXERCISED

Medical Records Clerks and other clerical personnel

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. Process 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.

2. Assists in the training and supervision of assigned clerical personnel.

3. Abstracts information from medical records for statistical indexing and for the preparation of summary reports to official agencies requesting medical information on patients.

4. Maintains statistical records on special studies; prepares narrative, statistical and graphic reports for hospital use or for official agencies.

5. Consults with doctors, nurses and other personnel in order to issue complete, up-to-date and accurate medical records.

6. Assists medical staff in compiling data for research projects.

7. When required, prepares hospital records to be taken to court and assumes responsibility for the return of such records to their proper place.

IMPORTANT AND ESSENTIAL KNOWLEDGES, SKILLS, AND ABILITIES

Knowledge of: The International Classification of Diseases and Operations used in medical record administration for coding and classifying diseases and their complications; the use of data gathering techniques as pertains to abstracting and report writing; principles of supervision, including clerical training.

Ability and Skill to: Recognize and follow-up inconsistencies in medical records; gather and arrange data in a logical sequence to be used in narrative, statistical and graphic reports; keyboarding ability of 40 net words per minute on a computer; establish and maintain cooperative working relationships with the general public and departmental personnel.

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, or release of medical information;

License and Certification:

Possession of a valid Registered Health Information Technician (RHIT) certification

Substitution:

Possession of a valid Registered Health Information Administrator (RHIA) certification may substitute for the required experience and the RHIT certification.

SUPPLEMENTAL INFORMATION

PROMOTIVE LINES

2114 Medical Record Technician Supervisor

ORIGINATION DATE: 2/18/75

AMENDED DATE: 10/30/15

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