135.1

These positions support the delivery of health care by developing, organizing, implementing and maintaining health information systems for accurate storage and retrieval of medical information in accordance with the standards of the institution, accrediting and regulating agencies.

T.H. Medical Records Director: (SL-5)

Directs and coordinates all Medical Records activities; plans and develops medical record retention, preservation and retrieval systems in accordance with hospital goals; oversees and updates the hospital on all legal, medical, local and financial regulations and ensures compliance. Establishes appropriate methodology for classifying and indexing systems best suited to the hospitals needs and develops, promulgates and revises medical records goals, procedures and guidelines. Directs the analysis of records utilization and designs systems improving their usefulness; develops standards for the retention of records to assure confidentiality and availability. Supervises personnel engaged in the collection, analysis, coding, maintenance and retrieval of medical records; supports health care activities by participating in various hospital committees. Collaborates with the Computing Center in the design and revision of components for the medical information systems; oversees and participates in the instruction and training of students and medical staff regarding the Medical Records Administration Program, which includes structured training sessions, orientation meetings and lectures. Participates and represents the hospital at professional association activities; represents the department with medical staff and administrators to foster a timely, efficient, and accurate operation. Supervises subordinates. Responsible for the department’s budget, supplies and personnel.

BS in MR, RRA certification, six (6) years experience to include two (2) years in a supervisory/administration capacity in a teaching hospital (Appendix A). Masters degree in related field preferred.

State Title Code: 3744028

SUNY Title Code: 3600

Revised: 10/1/87

135.2

T.H. Medical Records Associate Director: (SL-4)

Functions as chief of operations; manages the department and assists the Director in decision-making and reorganizing, planning and controlling day-to-day operations. Manages the department’s retention, preservation and retrieval systems in accordance with hospital goals; responsible for the departments quality assurance program; coordinates the updating of all legal, medical and financial regulations and ensures compliance. Develops and implements appropriate methodology for establishing classification and indexing systems best suited to the hospital'’ needs and assists in developing, promulgating and revising Medical Records’ goals, procedures and guidelines. Supervises the analyses of records utilization and designs systems to improve their usefulness; develops standards for the retention of records to ensure confidentiality and availability. Supervises subordinates engaged in the collection, analysis, coding, maintenance and retrieval of medical records; supports health care by participating in appropriate internal and external organizations and committees; coordinates and participates in the instruction of students and medical staff about Medical Records Administration Program; interacts with clinical and administrative departments to promote the achievement of department goals. Supervises subordinate staff; represents the department in the director’s absence.

BS in MR, RRA certification. Four (4) years of experience to include two (2) years in management. Masters in related field preferred.

State Title Code: 3744024

SUNY Title Code: 3601

Revised: 10/1/87

134.3

T.H. Medical Records Assistant Director: (SL-3)

Primary responsibility for assigned subfunctions within Medical Records (i.e. correspondence, file room, the evening operation, quality assurance, coding division, DRG operation, data gathering); coordinates the implementation of a unit’s internal quality assurance program, and assists with the planning and development of records retention, preservation and retrieval systems in accordance with the institutional standards and regulatory agency standards. Based upon assigned areas, the assistants may supervise and be responsible for the following duties and responsibilities as they relate to an assigned area: Supervises data gathering and documenting data reliability; assists health care practitioners to develop meaningful evaluation system, designs worksheets, screens medical records using established criteria, presents “deficient” cases, obtains statistical information for data displays and provides staff with “model” guideline and teaches audit techniques. Determines the incidence of various relevant review topics for the use of committee and individuals; supervises the screening of medical records for compliance with established criteria, designating exceptions or equivalents. Provides technical expertise to audit surveyors, and assists in the preparation of all surveys; participates in the selection and designing of all forms; ensures ongoing surveillance of practice indicators or monitors for medical staff review, retrieves criteria sets and data, conducts studies, evaluates results and insures the completion of each audit. Evaluates methods for improving primary source data to facilitate data retrieval analysis, tabulation and display; evaluates regulatory requirements to insure hospital compliance and designs formats to aid in reviews. Reviews performance against accepted standards and educates various groups on audit methodology; assists in developing standards to assure confidentiality of patients and physicians records and alerts the departments, the Quality Assurance Coordinator and Director of medical Records of all bonafide record documentation deficiencies identified. Participates in the department’s quality assurance program; develops criteria, abstracts data, displays deficiency trends and trains staff in techniques; supervises the processing of laboratory reports and ensures the collation of such reports within the medical records, and maintains statistics as to volume and status on all laboratory reports from nursing and the clinic area. May be responsible for developing and implementing the Concurrent Chart Program; assists in determining appropriate methodology and standard classification and indexing best suited to the hospitals needs, developing, promulgating and revising department record goals, procedures and guidelines. Assists in maintaining record confidentiality and availability; supervises the collection, quantitative analysis, coding maintenance and retrieval of the hospitals medical records, transcription of reports and incomplete charts linked to a suspension program; participates in related hospital committees as assigned. Participates in inservice training courses holding orientation meetings and lecturing on various aspects of Medical Records Administration; attends professional association activities and assists in the quality testing of approved hospital forms as they relate to program goals and regulatory standards. Supervises the subordinate staff.

BS in MR, RRA certification. Three (3) years of experience to include one (1) year in a supervisory/administrative capacity. Master’s Degree in related field preferred.

State Title Code: 3744020

SUNY Title Code: 3602

Revised: 10/1/87

135.4

T.H. Medical Records Specialist: (SL-2)

Supervises and participates in the conduct of interim reviews to confirm billing, computer entry and data quality; reviews codes and analyzes the medical records to ensure compliance with fiscal and regulatory requirements; provides inservice training as a routine function to staff directly and indirectly involved in the coding unit which includes other health related practitioners whose knowledge of coding is critical to the financial well-being of the facility; coordinates activities between department supervisory staff, Business Office and Utilization Review Department. May participate in concurrent diagnostic and operative coding verification and works with the DRG Coordinator as it directly relates to the coding of medical records; prepares and maintains medical records for the purpose of diagnostic and operative medical coding; ensures the selection of accurate and descriptive codes from the appropriate classification system; accurately classifies conditions and illnesses. Determines standard nomenclature for classification systems; assures retrievability and generally assists in meeting regulatory requirements; determines the order of primary, secondary and tertiary diagnosis to assist Accounts Receivable. Insures efficient and timely billing procedures; assists in the retrieval of billing documentation; completes necessary data for billing area and assures timely preparation of insurance requirements; ensures the completion of source documents for computer entry and collates files of previous admissions to verify systemic diseases; determines which of the several classification systems should be used or how the classification system should be modified to meet particular needs to facilitate the identification of disease/surgical/therapeutic procedures. Analyses medical records to ensure that the most suitable code is used; directly enters codes on the proper source documents, abstracts data; collates files of previous visits if needed and prepares charts for reviewers, studies and audits, and prepares charts as requested. Maintains timely Diagnostic and Operative Indices; maintains optimal standards for coding; assures uniformity of coding; implements hospital specific codes and discusses “problem” charts and issues within the department with the proper authority. Assists in developing and implementing policies and in training staff on procedures and policies consistent with state-of-the-art coding principles and guidelines and maintains updated policies and procedures. Provides hands-on assistance regarding the outpatient, ambulatory, concurrent and interim coding needs of the hospital. Ensures the confidentiality of data contained in the patients medical record as discussed in the institution; supports and promotes the Medical Record Department by participating in special projects.

BS in MR. RRA eligible, ART or CTR (Cancer Registry) enrolled in ART correspondence course plus two (2) to four (4) years of experience within the medical record field plus one (1) year in a supervisory/administrative capacity.

State Title Code: 3744031

SUNY Title Code: 3604

Revised: 10/1/87

135.5

T.H. Medical Records Senior Specialist: (SL-3)

Has specialized knowledge in the areas of coding medical legal correspondence, chart incompletion, terminal digit record keeping; supervises data gathering and documents the reliability of data produced at all levels, works with the Quality Assurance Coordinator and health care practitioners in the development of a meaningful evaluation system; selects and designs worksheets; screens medical records using established criteria; presents “deficient” cases, obtains statistical information for data displays; provides staff with “model” guide¬lines and teaching audit techniques to staff. Assists in screening medical records for compliance with established criteria and helps designate exceptions or equivalents; assists the Quality Assurance Coordinator in providing techni¬cal expertise to audit surveyors; participates in the preparation of surveys and be preparing written guidelines that can be followed by “non-audit” trained individuals; participates in the selection and design of all forms used with the medical record for data display. Evaluates methods for improving primary source data to facilitate data retrieval, analysis, tabulation and display, to structure a Quality Assurance Program meeting the agency requirements and needs. Evaluates regulatory requirements to insure hospital compliance, designs formats that will aid the committee reviews and performance against accepted standards and educates administration, clinical and student groups on Quality Assurance methodology. Provides hands—on assistance and supervision to the Incomplete Chart Review, Qualitative Analysis, Transcription and Forms Unit, and is responsible for data accuracy and computerization of unit reviews. Directs the flow of medical records and is responsible for maintaining the accuracy and reliability of retrieved data, also insures that records are in compliance with regulatory requirements; coordinates activities with other departmental supervisory staff, the Business Office, Utilization Review Depart¬ment, Health Care Practitioners and Administrators as they relate to the Incomplete Chart Review, Qualitative Analysis, Transcription and Forms Unit. Maintains the computerization files of the units and seeks ways to improve chart flow; maintains timely listings of incomplete and delinquent records; provides productivity reports and monitors the efficiency of the unit. Partic¬ipates in the department’s inservice education programs; provides inservice training as a routine function to staff directly and indirectly in the Incom¬plete Chart Unit, Qualitative Analysis, Transcription Forms, or Concurrent Review Section, including other health care related practitioners whose knowl¬edge of charting requirements is critical to the financial well-being of the facility. Assists in developing and implementing and maintenance of policies and trains staff on procedures and policies consistent with state-of-the-art charting requirements; maintains the confidentiality of information contained in the patients; charts, insures against any unauthorized disclosures. Sup¬ports and promotes the department by participating in other assigned duties; provides direct hands-on assistance in administering the hospital’s Concurrent ORG Program; assists in physician assignment review and completion actions; directs staff to the appropriate departments/services.

BS in MR, RRA certification. Four to six years experience with two years in a supervisory/administrative capacity.

State Title Code: 3744030

SUNY Title Code: 3603

Revised: 10/1/87

135.6

T.H. Medical Records Assistant I: (SL-2)

This position may supervise less technical sections within the department such as the file room and microfilm. Responsible for the day-to-day activities of that section; could also be medical records coder trainees or medical records coders in less complex setting such as the out-patient areas.

Associate’s preferred or College credits in appropriate field of study with zero (0) to three (3) years of experience.

State Title Code: 3744021

SUNY Title Code: 3605

Revised: 10/1/87

135.7

T.H. Medical Records Assistant II: (SL-1)

May supervise technical areas of the technical support section of the department such as correspondence, transcription, and incomplete room. May also function as off shift supervisor. Guides and directs day to day activities.

Associate’s in Science or ART eligible or enrolled in ART study program with 30 college credits or BS with related medical experience, and zero (0) to two (2) years experience in the medical record field.

State Title Code: 3744022

SUNY Title Code: 3606

Revised: 10/1/87