GENERAL CLASS DESCRIPTION:
Under direct supervision, performs technical and allied duties related
to the review, abstracting and coding of medical information from documents,
reports, on-line data sources, and Utilization Review summaries initiated
in the hospital complex for statistical, administrative and billing purposes.
Duties may involve the use of personal computers, computer terminals and
a variety of software and/or conventional office equipment.
CHARACTERISTIC DUTIES AND RESPONSIBILITIES:
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Reviews and interprets discharge summary, clinical notes, laboratory reports,
consultation reports, operation and procedure reports, and various other
documents in medical records to determine
principal and secondary diagnoses, operations and procedures related to
specific periods of hospitalization or outpatient treatment.
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Verifies principal diagnosis and procedure as indicated by physician on
completed discharge summary/letter for each admission or visit.
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Verifies and properly sequences other pertinent secondary diagnoses and
procedures relevant to patient’s hospitalization for billing/case mix purposes.
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Clarifies diagnoses and operations in question through use of various reference
materials, e.g., medical dictionaries, medical texts, and laboratory manuals.
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Assigns appropriate classification codes for diagnoses, operations, and
procedures and enters the code numbers into the computerized on-line abstracting
system.
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Extracts additional pertinent patient data items from various documents
and reports and enters the data into the computerized on-line abstracting
system.
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Analyzes and records data from Utilization Review documents for reporting
to state Professional Standards Review Organization.
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Reviews all Medicare/Medicaid patient records for staff physician/dentist
involved in patient care.
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Identifies specific categories of tumor referral to the Oncology Registry.
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Tabulates and summarizes medical information from indexes, statistical
reports, medical records, and other related sources as directed by supervisor
for research purposes.
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Types various reports, letters, and documents as required.
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Performs other clerical duties as required
The tasks listed under the heading of Characteristic Duties
and Responsibilities are examples of the variety and general nature of
duties performed by employees in positions allocated in the class. The
list is descriptive only and should be used for no other purpose. It is
not intended that any position include every duty listed, nor is it intended
that related duties cannot be required.
KNOWLEDGE, SKILLS, AND ABILITIES:
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Knowledge of medical record coding practices, procedures, and reference
sources.
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Knowledge of medical terminology.
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Skill in operating office equipment.
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Ability to communicate effectively with staff, students, and the public.
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Ability to follow oral and written instructions and interpret institutional
and other policies accurately.
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Ability to gather and analyze data and display in appropriate format and
maintain accurate records.
CLASS SPECIFICATIONS:
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Certification or eligible for certification as a Registerd Health Information
Administrator (RHIA), Registered Health Information Technician (RHIT), Certified
Tumor Registrar (CTR), Certified Coding Specialist (CCS),
or
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Two years of related experience, or
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One year of health information experience and one year college level courses
in physical or natural sciences.
REVISION EFFECTIVE: September 19, 2002
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