Classification and Compensation
IOWA STATE BOARD OF REGENTS
REGENTS MERIT SYSTEM
Pay Grade: 508
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
- 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.
- Verifies principal diagnosis and procedure as indicated by physician on completed discharge summary/letter for each admission or visit.
- Verifies and properly sequences other pertinent secondary diagnoses and procedures relevant to patient’s hospitalization for billing/case mix purposes.
- Clarifies diagnoses and operations in question through use of various reference materials, e.g., medical dictionaries, medical texts, and laboratory manuals.
- Assigns appropriate classification codes for diagnoses, operations, and procedures and enters the code numbers into the computerized on-line abstracting system.
- Extracts additional pertinent patient data items from various documents and reports and enters the data into the computerized on-line abstracting system.
- Analyzes and records data from Utilization Review documents for reporting to state Professional Standards Review Organization.
- Reviews all Medicare/Medicaid patient records for staff physician/dentist involved in patient care.
- Identifies specific categories of tumor referral to the Oncology Registry.
- Tabulates and summarizes medical information from indexes, statistical reports, medical records, and other related sources as directed by supervisor for research purposes.
- Types various reports, letters, and documents as required.
- Performs other clerical duties as required
Knowledge, Skills, and Abilities
- Knowledge of medical record coding practices, procedures, and reference sources.
- Knowledge of medical terminology.
- Skill in operating office equipment.
- Ability to communicate effectively with staff, students, and the public.
- Ability to follow oral and written instructions and interpret institutional and other policies accurately.
- Ability to gather and analyze data and display in appropriate format and maintain accurate records.
- 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
- Two years of related experience, or
- One year of health information experience and one year college level courses in physical or natural sciences.