GENERAL CLASS DESCRIPTION:
Under general supervision, performs complex technical and related duties
to analyze, review, abstract, code, and conduct risk surveillance on medical
information from a variety of hospital data sources on a decentralized
basis in the clinical departments and patient care units for hospital statistical, administrative,
billing, and risk surveillance purposes. Duties may involve the use of
personal computers, computer terminals and a variety of software and conventional
office equipment.
CHARACTERISTIC DUTIES AND RESPONSIBILITIES:
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Concurrently reviews and interprets medical record documentation in both
hard copy and computerized formats to determine the diagnoses and procedures
for a specific period of hospitalization. Assigns appropriate ICD-9-CM
code for each diagnosis and procedure. Determines principal diagnosis and
procedure and properly sequences all secondary diagnoses to ensure accurate
DRG assignment.
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Performs data entry into on-line medical record abstracts and verifies
accuracy of data downloaded to the abstract from other computerized functions.
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Determines the appropriate onset of diagnosis indicator for each diagnosis
to identify adverse outcomes for the UIHC Risk Surveillance Program. Collects
additional data on risk events as required. Identifies and reports sentinel
events to supervisor.
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Compares Transfusion Review Screening guidelines to medical record documentation
to verify the presence of physician orders, completed forms, monitoring of
vitals and signs/symptoms of reactions and indications for transfusion.
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Abstracts data for benchmarking, quality assessment or other studies. Compiles
and reports data as appropriate.
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Coordinates efforts with clinical department chart control staff to retrieve
delinquent medical records.
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Analyzes inpatient records for completeness according to JCAHO guidelines
and UIHC policy. Summarizes data as requested.
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Reconstructs medical records according to UIHC guidelines.
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Performs audits and prepares special reports as directed.
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Assists in the training and instruction of new employees and Health Information
Management students.
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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Ability to interpret and compare screening guidelines, criteria or definitions.
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Skill in operating office equipment and various software programs.
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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 it in appropriate format
and maintain accurate records.
CLASS SPECIFICATIONS:
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Certification as a Registerd Health Information
Administrator (RHIA), Registered Health Information Technician (RHIT), Certified
Tumor Registrar (CTR), or Certified Coding Specialist (CCS) including one year
experience as a Health Information Technician or equivalent experience, or
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Three years related medical records experience including one year as a Health
Information Technician or equivalent experience.
REVISION EFFECTIVE: September 19, 2002
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