HomeMy WebLinkAboutMINUTES - 09101985 - 1.42 Pq
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POSITION ADJUSTMENT REQUEST No. /3 70 c�
Date: 8/19/85
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Dept. No./ Copers
Department Health Svcs/Hospital Budget U►tlx No. 054o Org. No. 6516 Agency No. 54
Action Requested: Classify none (9) 40/40 posit,io�s and one (1) P.I. position per the attached
list. -
Proposed Effective Date: 9/1)/85-
!Explain
/10/85!Explain why adjustment is needed: To augment Medical Records Department staffing.
Classification Questionnaire attached: Yes ® No []
?Estimated cost of adjustment $ 185,390/year
Cost is within department's budget: Yes ® No
If not within budget, use reverse side to explain how costs are to be funded.
'Department must initiate necessary appropriation adjustment, Web Beadle, Department
Use additional sheets for further explanations or comments.
for Department Heaez d
Personnel Department Recommendation
Date: Cz S -6
Classify one-40/40 Medical Records Administrator position, Salary Level C5 1465
(1966-2389) ; one Accredited Records Technician 40/40 position, Salary Level C6 1312
1687-2050; one Medical Record Techlrician 40/40 position, Salary Level C5 1172
(1467-1783) ;five Clerk-Experienced Level 40/40 pos,itions,Salary Level C5 0964 (1191-1448) ;
one Data Entry Operator I 40/40 position, Salary Level C5 0922 (1142-1389) ; one P. I .
Secretary - Journey Level position, Salary Level T8 0943 (1257-1649) .
lmend Resolution 71/17 establishing positions and resolutions allocating classes to the
iasic/Exempt Salary Schedule, as described above.
affective: day following Board action.
a -v
Date (foe)- Director ofrPersonnel
;ounty Administrator Recommendation
Date:
p Approve Recommendation of Director of Personnel
D Disapprove Recommendation of Director of Personnel
6 Other:
for County Administrator
oard of Supervisors ActionPhil Ratchilor, Clerk of the Board of
djustment APPROVED/BtSAPVI ED on SEP 10 1985 Saperti s0s5 a .un�y,ac?Inlrisuator
ate: SEP 101985
By:
1PROVAL OF THIS ADJUSTMENT CONSTITUTES A PERSONNEL/SALARY RESOLUTION AMENDMENT.
306 M347 6/82
VOTE OF SUPERVISORS
UNANIMOUS (ABSENT ) I HEREBY CERTIFY THAT THIS IS A TRUE
AYES: NOES: AND CORRECT COPY OF AN ACTION TAKEN
ABSENT: ABSTAIN: AND ENTERED ON THE MINUTES OF THE BOARD
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ATTACHMENT TO P-300
AUGMENTED MEDICAL RECORDS STAFFING
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CLASSIFY THE FOLLOWING NEW POSITIONS:
Functional
�l pos Pos type Class Assignment
1 40/40 Medical Records Admin. Outpatient Svcs.
1 40/40 Accredited Records Tech. Supv, Discharge Analysis Unit
1 40/40 Medical Records Tech Leadworker - CTL File Room
(nights)
5 40/40 Clerk - Experienced Level Central File Room clerks
(non-typing)
1 40/40 Data Entry Operator I Data Entry
1 P.I. Secretary - Journey Level Secretary to Chief, Medical
Records Admin & Assistants
10 positions total
EMPLOYEE NAME
1. What is the function of your work unit?
Secretary to Chief Medical Record Administrator. Ensure smooth processing of
paperwork and work flow through office.
2. For whom or for what group are you providing clerical support?
Medical Record Administrative Team consisting of Chief Medical Record
Administrator, 3 Medical Record Administrators.
3. Designate the name and title of the person who supervises your position.
How-is your work reviewed?
Gail Moser, RRA, Chief Medical Record Administrator.
4. Where is your supervisor located in proximity to your desk?
Not applicable.
5. What are the most important assignments you perform and why?
1. Attend meetings and prepare accurate minutes. This requires extensive
knowledge of policies, procedures, operational functions.
2. Processing paperwork pertaining to employee positions, grievances,
disciplinary actions. This requires knowledge of various job functions,
department/union interaction process, personnel procedures. Also
requires high level of discretion as all information pertaining to
6. What 4VkqWfts* f6YPfW -complex work you perform and why?
Meeting deadlines for tasks assigned by multiple managers. Tasks (and
managers) often have conflicting priorities.
7. What parts of your job involve the greatest responsibility and why?
Maintaining high level of accuracy in all aspects of job. This is
particularly true when preparing minutes of various meetings, especially
when issues discussed are technical, complex, and conflicts exist between
managers.
8. List the name and job titles of employees to whom you are assigned to provide
lead direction.
None.
9. Do you deal with extraordinarily difficult, angry or potentially explosive
Persons? Provide an example and indicate the frequency of these contacts
and what your responsibility is in these situations.
Not applicable.
10. How long have you been in your current position? -
Years) Mont s
11. Where were you assigned before this position? Desk, Department, Location,
Assignment.
Not applicable.
(signature) (Date)
CLASSIFICATION QUESTIONNAIRE (CONTINUED)
Secretary Level A Page 2
Percent Of Description of Work:
Time Required
G - 5% G. Coordinate special projects and prepare reports.
H - 5% H. Process and have access to confidential information, including:
1. Union issues
2. Grievances
3. Employee personnal files
4. Correspondence between management and employees
5. Administrative progress reports; goals and objectives
I - 5% I. Check accuracy and/or completeness of incoming reports, including:
1. PIS reports
2. Computer printouts dealing with staff, budgets and finances
for 3 cost centers
J - 5% J. Distribute information to staff.
Advise administrator when requested.
Type EVERYTHING.
K-- 2.5% K. Requisition supplies. Check L-3s and invoices for accuracy and
completeness.
'L - 2.5% L. Design forms, including:
1. Format for tickler files
2. Format for minutes of meetings
3. Format for agendas
;M.- 2% M. Monitor employee time sheets and expense demands. Advise payroll
and/or personnel of changes.
II. Secretarial support to Medical Record Administrators, Project,
Inpatient and Outpatient
A. Take and transcribe minutes of meetings using shorthand and/or
tape recorder.
B. Attend meetings.
C. File and retrieve information.
D. Type policies, procedures, correspondence.
E. Distribute information to staff.
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CLERICAL DEEP CLASS
CLASSIFICATION QUESTIONNAIRE
Vacant Health Services Hospital C.C.C.Hospital
Name Department Division Work Unit
Secretary Level Ar---� 2500 Alhambra, Martinez
Job Classification Work Location & Address
Percent Of Description of Work:
Time Required
I. Secretary to Chief Medical Record Administrator. Duties include: '
A - 22% A. Attend meetings, prepare agendas for meetings, take minutes
using shorthand and/or tape record. Meetings include:
.l. Administrative/Supervision, weekly
2. Medical Record All Staff, monthly
3. Central File Room Unit
4. R.O.I.
5. Inpatient/Discharge Unit
6. Outpatient Unit
B - 13% B. Take dictation and transcribe correspondence and reports in
draft and/or final form.
Compose correspondence into draft and/or final form.
C - 13% C. Maintain files and retrieve requested information. Files
include:
1. Budget and financial files for 3 cost centers
2. Personnel files
3. Administration files
4. Medical Record Policy and Procedure Manual
5. Department Policy Manual
6. Contra Costa County Policy Manual
7. Resource Guide
8. Title 22/JCAH/Title 10
9. Miscellaneous files (minutes of meetings, special projects,
etc. )
Maintain tickler files, including:
1. Employee evaluations
2. Budget information needed for 3 cost centers
3. Employee health exams
4. Professional continuing education credits for RRA/ART
D - 10% D. Answer phones, screen calls, take messages.
Screen visitors (includes patients, contractors, salesmen,
employees from other departments) .
Keep appointment calendar and make•appointments for
administrator; protect administrat6r's free time.
Organize and prioritize main and incoming duties into
classifications.
Schedule and set up meetings; arrange space/refreshments as
needed.
E - 1% E. Act as resource person for questions/problems/referrals
regarding policies and procedures. . Also trouble-shoorter and
problem-solver in administrator's absence.
F - 4% F. Type. all procedures for Medical Record department on CPT and
keep them updated as changes occur.
January. 1982
List Machines or Equipment Operated as Part of Job:
CRT
Designate the name and title of the person who supervises position
Assistant to Chief Medical Record Administrator
List the names of employees supervised. It a whole unit is supervised simply name the unit on6 sae the number of employees.
None
If public contacts are required either in person or by phone, state with whom,and in general, for what purposes
None
What decisions must be made in performing the work:
when there are unexplanable system problems
What parts of the job require the greatest skill, knowledge, and involve the greatest responsibility
Data Entry
The above statements accurately describe this job as it has been for the post New Position and '
ears Months
(Signature) ( Date)
COMMENTS OF IMMEDIATE SUPERVISOR
In what way are the above statements incomplete, inaccurate or misleading:
Above statements are accurate
What is the basic purpose or function of this position ?
Data Entry of billing documents and entry of medical abstract infor-
mation into the billing system.
What changes have occurred in the work of this position ?
None
Whot ports of this job do you check or review closely c-.-.d why ?
Accuracy of data entry
It the position requires typing or shorthand, are they incidental cr essential 7
incidental
Typing: Time Required:
Shorthand: Time Required:
State what you believe to be the special certificates and minimu;n amounts of training and experience required to perform this job:
Required education: none
Required experience: ability to operate data entry machine at a
Required license or certificate: prescribed performance level .
(Signature) (Date)
COMMENTS OF DEPARTMENT HEAD
Comment on the statement of the employee and supervisor. Designate any other positions in the department which you believe are similar in duties and
responsibilities.
(Signatur _ (D,,;
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CONTRA COSTA COUNTY
C L A S S I F 1 C A T 1 0 N Q U E S T 1 0 N N A I R E
Health Services Hospital and Clinics
NAME DEPARTMENT DIVISION
Data Entry Operator I Medical Records, MTZ
Same
OFFICIAL JOB CLASSIFICATION WORKING JOB TITLE Place of Work and Assigned Hours
8-4:30 to start, may
Data Entry Operator I require moving to another
Time Required Description of Work: shift.
This position is responsible for:
1 . Data Entry of ICD-9-CM codes for outpatient services and Emergency
15% Room services into PATCOM System from various source documents (may
be coded and/or uncoded) .
5%
2. Updating various fields in PATCOM and Medi-Data systems from various
source documents (coded and/or uncoded) .
3. Data entry of outpatient surgery abstract information into Medi-Data
12% system from various source documents ( including the medical record) .
15% 4. Data entry of inpatient abstract information into Medi-Data
system from various source documents including the medical record.
3% 5. Data entry of elements necessary to compute DRG (Diagnostic Related
Group) into Medi-Data system from various source document;.
60 6, Performing DRG "grouping" functions on IBM PC/XT. Requires entering
data enements into computer.
3% 7. Maintenance od DRG Log, file and reports.
8. Data entry of incomplete record tracking information into IBM
20% PC/XT from various source documents.
9. Assisting Project Medical Record Administrator with system related
6% problems.
3% 10. Performing various patient search functions in PATCOM and Medi-Data
systems.
3% 11 . Generating reports and documents from various systems as required.
12. Investigating (sometimes with the assistance of the Project Medical
3% Record Administrator) miscoded, uncoded or other problem source
documents.
3% 13. May review computer printouts as they apply to Medical Records
especially in the area of the Billing Hold Report.
3% 14. Assisting with the development of and continue to maintain logs or
other records regarding productivity of data entry.
.,75
Page 3 - Clerk B Level Central File Room
REFERRALS
Referrals come to the office from the outlying clinic areas, referrin
2% the patient here 'for specialized care. These referrals must be filed
in the record in a timely manner and accurately in order for the
patient to receive the medical care needed. Referrals may also be
sent from the hospital to the clinics and again must be sent in a
timely manner to continue the medical care of the patient .
MARRIAGE CERTIFICATES
Marriage certificates are sent to our office by the Health Department
2% each time the lab slips are marked "Pre-Marital " . These marriage
certificates are logged into our office for quick reference, the lab
slips are filed into the chart , the certificate is paper clipped on
the last page of the chart . The doctor then reviews the lab slips
and if appropriate signs the marriage certificate. The patient then
is allowed to get a license for marriage . If 100 % accuracy is not
maintained, the patient may not be able to get married without having
additional lab work done.
PURGING
2% Records are purged from our files yearly . This involves determining
the date the patient was last seen by searching the entire record
for dates . If the patient has not been seen in the alloted time
frame, (currently 2 years) , . the chart is in-activated, and placed
in storage. The clerk must update the master outguide correctly in
order to track the chart for future reference.
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Page 2 - Clerk B Level Central File Room
If the nunber was issued to the Main Detention Facility , the chart
folder is created there .
TELEPHONES
Our office has 4 incoming phone lines with many calls coming in
4% daily . We must have knowledge of various laws concerning release of
information in order to- handle the calls. Responsibility lies with
the clerk to maintain appropriate patient confidentiality .
in addition, the clerk answering the telephone is the first one in
the office to greet the patient and must be courteous at all times.
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RUNNING
2% Charts are delivered to different areas of the hospital on an as
needed basis. In addition to the as needed deliveries, the clerk
also retrieves all records needing to be returned to file from anywhe
in the hospital .
CLINIC
All scheduled clinic visits must have a chart available at the time
12% of the clinic visit . To accomplish this, charts are pulled the
night before the clinic visit . This involves 400 - 600 charts in
an 8 hour shift . The charts are separated by clinic, by AM or PM
appointment time, and by doctor. They are delivered •'to several
locations in the hospital . Good organizational skills are required
in order to keep each clinic separate and delivered to the correct
area .
BIRTH CERTIFICATES
A birth certificate is completed for' each baby born in this hospital
or on the hospital grounds. This involves interviewing the mother,
2% asking her to complete a birth certificate information worksheet,
verifying this information , typing the certificate with 100 % accurac
obtaining the doctor 's signature, filing the certificate with the
health department . This job requires close personal contact with the
new mother on the ward.
DEATH CERTIFICATES
A death certificate is completed for each death that occurs within
2% the hospital and for some deaths outside the hospital , if the decease
was our patient . The clerk must be aware of laws pertaining to
Coroner '.s Cases , who may consent for autopsy and who may make funeral
arrangements. The clerk must deal occasionally with the family
members in a professional manner and must be keenly aware of the
feelings of these people. The certificate must be completed with
100 % accuracy as it is a permanent record.
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List f.icchlncs or Equipment Operated cs Part of Job:
Typei,riter, CRT, photocopier
:!osirnatc the Hare and title of tho person who supervises position '
Sue Swafford, ART
_:sl the names of emp.oyoes supervisoc. If n wnoic unit is supervisca simply name tna unit ane state the number of omD oyocs,
Sue Swafford supervises 3 shifts, Central File Room. The clerical positions will
not supervise
1! ,,-.abhc contacts are required either in person or by phone, state with whom, and in generals for what purposes:
The clerks frequently assist patients who come to the department for various
reasons. The clerics also assist .physicians and other health personnel from
the I-Iealth Services and other health care institutions as well.
What docisions r..usl be mode in performing the work: ...
The clerks must make decisions regarding operationalizing department policies
and procedures. They must also make decisions regarding release of information.
V.hat parts of the 100 require the groatest skid, knowledge, and involve the greatest responsibility
All aspects of the clerks duties require great skill. Failure to remember dept.
procedures or policies can have unfortunate, costly results.
The ctove statements accurately describe this job as it has boon for the past and
cars .onlhs
(Signature) ( Date)
COMMENTS OF IMMEDIATE SUPERVISOR
e
In what rvay ore lbs ohovo sloteme.nl:: In coctplu le, mace u:utn or
W'hct is the basic pu:psse or function of this position 7 '
Clerical
K:-ml Change- have o:curt rd 1, the work of this position 7
Fera changes except those that relate to the billing system.
What ports o: c.`.ia job do you chock or review closely and why P.
All parts are closely monitors,_. Telephones and Running are probably not monitored
as closely as other activities.
11 the position requires typing or shorthand, ata they incidental a: essential 7
Typing is not essential, minimal typing
Typing: Time Required: is helpful because of computer.
Shorthand: Time Required:
State what you Volieve to be the special certificates and minimum amounts of training and experience required to perform this job:
Required education:
Required experience: Non—typing
in
g
Required license or certificate:
(Signature 1 (Date)
COMMENTS OF DEPARTMENT HEAD
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Ccmmer.t on :!:e s.a!ement of the employee end supervisor. Designate any other positions in the department which you believe aro similar in dulios and
res Donsibilitics.
Signature)__,_ _ _ (Data
CONTRA COSTA COUNTY
t CLASSIFICATION QUESTIONNAIRE
•Health Services Hospital /Clinics
N AM..E DEPARTMENT DIVISION
CLERK B Level Central File Room 2500 Alhambra Avenue, Martinez
%F FICIAL JOB CLASSIFICATION WORKING JOB TITLE Place of Work and Assigned Hours
Clerical, Deep_Class, B Level Same Medical Records Dept. , MTZ
/
1A/0A./—Wp1 K
Time Required � Description of Work:
FRONT DESK.
This desk pulls charts for the Emergency Room and for admissions to
the hospital . If this is a new patient , a new chart folder is creat
and an outcard is filed for tracking purposes . The clerk on this de
works closely with Reception Center and must have the ability to get
along and work well with other people and departments. This clerk
10% also maintains a 3 x 5 card file for each new chart created and upda
the master outguide each time a new folder is placed on the shelf.
DISBiISSALS
The chart of each patient discharged from the hospital must be
obtained fro::, the ward on the day following discharge . It is then
10% re-arranged in final filing order. , copied appropriately for the oche
clinics and then refiled. The clerk must determine if this patient
has a health Plan record in addition to the hospital record and if s
convert t1ie chart or combine the healt,p plan record with the hospita
record to create only one folder . This requires accurate updating c
the master outguide each time . Ar outcard is written and placed in
a tickler file for the discharge analysis section to pull the same
chart c,rhen they are ready to analyze the chart .
IP;TEFFIL.?i:C
This desk. involves filing into the medical record all of the xray
25 ' reports , lab reports , operative reports , pathology reports , letters ,
etc . If these reports are not filed correctly , the doctor will not
have the information he needs to treat the patient and he may need t
reorder some tests , which is an unnecessary expense to the patient c
the Health Services Department .
DICTATION [-.EST'
There are multiple types of dictation done by doctors , each handled
ZDV° differently . The status of the patient must be determined by the
clerk, such as is the patient an inpatient , outpatient , still in the
hospital or discharged. Once this is determined, the report can be
filed . Copies of the dictated reports must be sent to the outlying
clinics for continuation of medical care . Some reports dictated by
physicians must be signed immediately and some may be filed into the
chart without signature , if the chart has not been analyzed . I.f the
dictation needs to be signed now, the chart must be made incomplete
in order to obtain the proper signature . This procedure has several
steps to completion: writing outcards, filing outcards in the centr,
file room, placing color coded stickers on the front of the chart ,
completing a "this chart lacks" form, color coding the report and tt
lack slip for the doctor, filing the .report in the chart and filing
the chart on the incomplete room shelf. This is very detailed and
must be completely accurate . The volume is heavy and requires sevc,z
hours per day to complete.
ISSUING mEr;r NUMBERS .
The central file room clerk issues new numbers to the Pain Detention.
2% Facility and to new County Health Services employees for their annua
physical examination . This requires knowledge of the PHS computer
system for screening to determine if a chart number exists prior to
issuing a new number . Once it. is determined that a number does not
exist , it is issued a,ld a f'nlr7er is created .
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List Machines or Equipment Operated as Part of Job:
Typewriter, CRT, Photocopier
Designate the name and title of the person who supervises position
Sue Swafford, ART
—ist the names o1 employees supervises, 11 n whole unit is supervised simply name the unit ane state e number of employees.
Central File Room Clerks, graveyard shift - 3 clerks plus back up to Swing shift MRT
11 public contacts are required either in person or by phone, state with whom,and in general, for what purposes
Public includes anyone who comes to the department for assistance which might include
requests to release information or requests from other facilities for medical information.
W'hot decisions must be made in performing the work:
Those regarding department and Hospital policy, alterations in the night's work flow,
management of clerks in such areas as shift coverage, interactions with supervisors,. etc.
What parts of the job require the greatest skill, knowledge,and involve the greatest responsibility
Knowledge of department procedures and how to implement them in various circumstances.
Managment of staff in performance of assigned tasks.
The above stat!}h"eHtsPGW° 19,aescribe this job as it has been for the post and
Years Months
(Signature) ( Date)
COMMENTS OF IMMEDIATE SUPERVISOR
In v,hot way are the above statements incomplete, inaccurate or misleading:
What is the basic purpose or function of this position ? -
To provide supervision to clericals and thus ensure continuity of work flow between the
three shifts.
What changes have occurred in the work of this position ?
New position.
What parts of this job do you check or review closely and why ?
Work flow, completion of assigned tasks, flow of information regarding work
between shifts, personnel management.
If the position requires typing or shorthand, are they incidental or essential 7
Typing can be at a speed of less than
Typing; Time Required: 40 WPM. Single line typing is
Shorthand: Time Required: all that is required.
State what you believe to be the special certificates and minimum amounts of traininc and experience required to perform this job:
AbilityRetaoeat«y3o)aelia40 words per minute/performance test not required
Requited experience• 18 months full time expe-rience in CCCHSD medical
record department
Requited license or certificate:
(Signature) .._ (Date f
COMMENTS OF DEPARTMENT HEAD
Comment on the statement of the employee and supervisor. Designate any other positions in the department which you believe are similar in duties and
responsibilities.
(Signatc- ._._.__ (Date)
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CONTRA COSTA COUNTY
f C L A S S I F I C A T 1 0 N Q U E S T I O N N A I R E
Health Services
NAME DEPARTMENT DI• Isl
Medical Record Technician, Central File Room (graveyard) 2500 Alhambra Avenue
OFFICIAL JOB CLASSIFICATION WORKING JOB TITLE Place of Work and Assigned Hours
Medical Record Technician Same Medical Records,MTZ.
Midnight to 8 AM
Time Required Des_ription of Work-
TRAINING
As MRT on the Graveyard shift. I am responsible for the continued training
of all employees on this shift. The duties performed on this shieft are:
35% chart arranging, copying appropriate records to send to outlying clinics,
issuing new charts for the Emergency Room and Admissions, interfiling
various items into the charts in the correct place and in the correct chart.
I train all new Central File Room graveyard employees in terminal digit
filing; completion of Death and Birth certificates; chart arrangement;
pulling of medical records for clinic; admitting and discharge procedures;
distribution of various medical record forms including histories and
physicals, operative reports and discharge summaries for patients who will
receive follow-up care in outlying clinics; chart transportation to patient
care areas. I continually monitor the work of these employees to assure the
maintenance /of ac/curate �output from them.
N �t1CJv�/( Dl✓ILG�y��/Ty�
I am responsible for the employees on the graveyard shift as far as the work
they are performing, assigning the duties to be performed and setting
aily priorities as assigned by the dayshift ART: 1 pull charts for the
45% 3creening nurse and Emergency Room as needed at night and in a timely manner
Cor the provision of medical care. I fulfill staff physician requests for
ininformation from medical records. I schedule employees appropriately for
he work needing to be done. I provide input into the evaluation process for
hese employees and I act as liaison person between the other two shifts
swing and day) . I monitor the workload closely to make sure it is tone in
timely manner and done correctly. I schedule employees for time off
aking sure the shift is covered appropriately.
ACK UP
I am the person providing back up to all clerks in the office on the graveyard
10% 5hift and will occasionally work another shift in an MRT position such as
in times of sick leave or vacation. I must be able to perform any duty
ithing the central file room in case of backlogs or emergencies.
PUBLIC ASSISTANCE
I assist the public when they present to the central file room in person
10% r on the telephone. I must be aware of all hospital forms, accrediting
nd licensing agency requirements, release of information policies and
olicies regarding confidentiality of patient information in order to
roperly assist anyone coming in or calling. I must use my own judgment
nd I must make independent decisions based on knowledge of medical record
epartmental policies.
I
AK 75
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List Machines or Equipment Operated as Part of Job:
CRT, occasional use of the typewriter
Designate the name and title of the person who supervises position
Medical Record Administrator (Inpatient Services)
�.isl the names of employees supervised. If n whole unit is supervised simply name the unIt and sae the number of employees.
Inpatient Analysis and Coding Unit
If public contacts are required either in person or by phone, state with whom,and in general, for what purposes
Few planned public contacts
What decisions must be made in performing the work:
Once procedures are in place,. far fewer decisions must be made. However, in the
beginning, this ART must question the entire scope of the unit. This will ultimately
assist the unit in streamlining operations.
What parts of the job require the greatest skill, knowledge, and involve the greatest responsibility
Coding in ICD-9-CM (accuracy is the greatest responsibility)
Skill also in the aggregation and display of statistical data.
The above statements accurately describe this job as it has been for the past and
ears ont s
(Signature) ( Date)
COMMENTS OF IMMEDIATE SUPERVISOR
In what way are the above statements incomplete,inaccurate or misleading: ,
All are accurate
What is the basic purpose or function of this position 7
To supervise the Abstracting and Coding Unit
What changes have occurred in the work of this position ?
For many years this position has not seen changes in several task areas. However, with
the advent of the computerized billing system the unit--its' efficiency and accuracy
have become far more important
What parts of this job do you check or review closely and why 7
Those as related to the Billing Hold Report and hospital licensing and accrediting
requirements.
It the position requires typing or shorthand, are they incidental or essential 7
incidental
Typing: Time Required:
Shorthand: Time Required:
State what you believe to be the special certificates and minimum amounts of training and experience required to perform this job:
r 3
Required edueatior VL auiia t-iVii friiiti all isi�ti-i aii(i r'vuCi"il:all ZieLLll:a1 1(C-'I:UL'LL assoc. approve
program as an Accredited Record Technician or Registered Record Adm.
Required experienc;.`itl'in 12 .i-1nth.- of e„lplc.yment, appointees must pass an exam for Assoc
Required license or certificate: certification as an ART or RRA issued by the American Med. Rec./
l Signature) (Date) ,
COMMENTS OF DEPARTMENT HEAD
Comment on the statement of the employee and supervisor. Designate any other positions in the department which you believe are similar in duties and
responsibilities. ,
(Signature 1 (Dot*
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fir , CONTRA COSTA COUNTY
f C L ASSI F I CAT ION QUEST IONN AIR E
Vacant Health Services Hospital & Clinics
NAME DEPARTMENT DIVISION
Medical Record, MT7,
Accredited Record Technician Same Monday tnru Friday Days
Discharge Analysis Unit
,OFFICIAL JOB CLASSIFICATION- WORKING JOB TITLE Place of Work and Assigned Hours
Time Required �jf ERVISLON: Description of Work:
Responsi e for direct supervision of discharge anai.yc-.:;.:_ cler}s 'Medical
Record Technicians) who conduct a complex technical analysis of medical
records after the patient has been discharged to assure compliance with
0
federal and state licensing bodies, and accreditation requirements for
60/ medical --e=d .-e-_v;c_s. I we--k d.i,-ectly wiitil Patient Acco;na_ii-.g, II-ili_.aticn
3.ev-'.e-1Frio Date. ?--oceEsirl.g !,epar:ver.._ W. th '"e€a d.^ to yroblems related _c
billing.
I supervise the coding (using International Classification of Diseases,
9th Revision, CliIlical 1•1iGdi l:atlon) Of all' inpatient discha ,es. T'iiis
activity is both for the purpose of billing and for the development of
indices (as mandated by Title 22) to be used to retrieve medical information
for Doctors, Auditors and various types of health care professionals. As
part of this supervision I must must incorporate quality coding controls,
perform quality control studies and provide inservice when necessary as
well as on an ongoing basis.
I supervise the abstracting of surgical information for SIMS (Surgical
Indications Monitoring) which is provided on a periodic basis to the
Patient Care Monitoring Committee (of the Quality Assurance structure).
TECHNICAL SKILLS
I must posess exceptional ICD-9-CM coding skills and read literature
40% that comes out in professional journals to keep my skills updated.
I must have an indepth understanding of abstrac-ir..- fo-- STNS. I must have
knowledge of methods of collecting medical statistical data, diagnostic
coding systems used and be able to inerpret these for medical staff.I
must have knowledge of methods of aggregation and display of statistical
data.
In the event that any MRT is absent, I Aust be able to perform any of
their technical. duties.
1 is:i' lCiE writteF.. pl-oceCTi✓a i guidea aI7d rev:isicll of all. C.ut.-ies assigned
to the unit's personnel. These written procedural guides are forst.--ded.
to the Medical Record Administrator in charge of the unit.
I must be able to assi:roe the c'.uties and responsibilities for Accredited
Record Technicians in their absence.
I perform other duties as assigned by the Medical Record Administrator
in charge of the unit (ultimately the Chief Medical Record Administrator).
1 attend classes, saorlishopE, ser_na--s and inc-ervice training programs
relative to the pcsi. .:ort and t:: the Eir:erican Meei cal. Record Association's
requirement for continuing education.
I
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Page 2 Medical Record Administrator (Outpatient Services ) i
PROFESSIONAL ENRICHMENT
l I maintain thorough, current knowledge of medical record science. I
pursue a continuous program of formal and informal education in health
record administration and management.
INSERVICE EDUCATION
I plan for and provide inservice education to all outpatient medical
1 record areas.
r,
I
List Machines or Equipment Operated as Part of Job:
CRT
Designate the name and title o! the person who supervises position
Gail A. Moser, RRA, Chief Medical Record Administrator
List the names of employee s
mp oyees supervise c, n whole unit.is supervise simply name a unitone state e number a employees,
Outpatient Medical Record Departments
1t public contacts are requires either m person or by phone, slate with whom, and in genual, tar what purposes
Mpst public contacts would. probably occur around release of information.
What cecistons must be made in performing the work:
How to prioritize work, decisions regarding_ release of information, decisions regarding
the billing system and medical record system, decisions regarding when to advise immediate
supervisor.
Khat porta of the loD require the g:valest skill, knowledge, and involve the greatest responsibility:
Supervision of various outpatient medical record areas and assuring a county-wide
compatible medical record system. In depth knowledge of medical record science as
Twell as }abiT7ll'ity to manage people. will prove to be the biggest assets.
TBeea ovPeOgl is nr,l3 accurately describe this job as it has been for the pant and
Yearn Months
�/�Si gnature} ( Dat*)
^• COMMENTS OF IMMEDIATE SUPERVISOR
In what way are the above statements incomplete, inaccurate or misleading:
Above statements are accurate
What is the basic purpose or function of this position ? "
Supervison
Systems (medical record) management and control.
W=t c-cr.ges have occurred in the work of this position ?
New Position
What parts e: this job do you check or review closely and why ?
System wide compatibility of medical record procedures
II t.^.e position requires typing or shorthand,are they incidental or essential ?
TGV.-i.n_go is incidental,
. -
Typing: Time Requiredt
Shorthand: Time Required:
State what you believe to be the special certificates and minimum amounts of training and experience required to perform this job:
Required education: Bachelors Degree in Medical Record Management.
Required experience:Must have performed medical record administrative duties within the
last 5 years or must have graduated from an approved MRA program w/in last 5 years.
Required license or certificate:
RRA certificate or eligibility for registration with the
(Signature) (Oat*)
Amogin2n Mcirli r^l Rarnrr3 Ac nri nti on
COMMENTS OF DEPARTMENT HEAD
Comment on the statement of the employee and supervisor. Designate any other positions in the department which you believe are similar in duties and
responsibilities.
(Signc,..rv) -- -�.� (Dote,
it
CONTRA COSTA COUNTY
f CLASSI FICATION QUESTIONNAIRE
Health Services
AME DEPARTMENT DIVISION -
Medical Record Administrator Same Hospital/Clinic
FFICIAL JOS CLASSIFICATION WORKING JOB `ITLE place of Work and Assigned Hours m
Monday thru. Friday
Modical Record Administrator- (Outpatient Services) 2500 Alhambra Avenue
T.;Me Required Supervision- Description of Work:
_
I`am responsible for the day-to-day supervision of Medical Record personnel
75 involved in outpatient Medical Record tasks at 12 different clinic sites.
I visit all outpatient sites on a regular basis to plan work schedules,
develop and implement procedures,., evaluate personnel , supervise activities and
resolve issues. I am responsible for assuring continuity of all outpatient
Health Services Department Medical Record services.
After confering w th the Chief Medical Record Administrator I make sure
that all sites are using appropriate policies and procedures for such medical
record tasks as chart retrieval , chart delivery, indexing, interfiling,
coding diagnoses and procedures, data collection, release of information, etc.
I conduct periodic evaluation on 4 ART's and 5 MRT's engaged in outpatient
Medical Record services. I also set goals and objectives for these employees
that will assure that needs of the clinics and Health Services Department
are met in a timely and provessional manner.
I held regular meetings with individual supervisors and clinic managers
to make sure the operationtil- needs of clinics are met. I also hold regular
meetings with the entire Medical Record professional outpatient staff to
assure uniformity.
I confer with and advise clinic managers and the Chief Medical Record Adm-
inistrator regarding outpatient policies and procedures, licensing and
accreditation requirements ( including Title 22 and JCAH) , and I am responsible
for assuring all standards are met. To meet this requirement I have an
outpatient quality assurance plan that periodically monitors and accesses
medical records and associated tasks.
I. assure that all outpatient medical record areas perofrm in compliance with
County Health Services standards witb regard to timely coding, data entry
and hatching of outpatient billing information, etc.
I assure that all documentation in the Outpatient Clinic Sites is
adequate and follows guidelines of funding sources (eg• grants,
Medi-Cal , Medicare) .
am responsible for assuring the accuracy of all billing/coding procedures
performed by outpatient Medical Record personnel to maximize revenue.
I provide technical backup to sub ordinates if necessary.
MANAGEMENT LIAISON
I assist the Chief Medical Record Administrator and clinic managers in the
15 preparation and monitoring of Medical Record outpatient budgets. I monitor
effective utilization of physical and financial resources of CCCHSD.
I provide weekly reports to the Chief Medical Record Administrator,
I maintain viability of matrix management network in all Outpatient medical
record areas.
LEGAL REQUIREMENTS
8 1 represent the Health Services Department in courts of law on release of
the Department 's outpatient medical information as a designee of the
Custodian of medical records.
I assure that se of information policies and procedures are uniform
throughout - tient Medical Record areas and in compliance with all
uniform---
legal rec s approved by the Chief Medical
AY 75 Record Administrator.
{ 1, PERSONNEL ADJ APPRVD 1370$.
�2 . HEALTH SVCS PUBLIC HEALTH j