Classification and Compensation
IOWA STATE BOARD OF REGENTS
REGENTS MERIT SYSTEM
Pay Grade: 510
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
- 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.
- Performs data entry into on-line medical record abstracts and verifies accuracy of data downloaded to the abstract from other computerized functions.
- 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.
- 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.
- Abstracts data for benchmarking, quality assessment or other studies. Compiles and reports data as appropriate.
- Coordinates efforts with clinical department chart control staff to retrieve delinquent medical records.
- Analyzes inpatient records for completeness according to JCAHO guidelines and UIHC policy. Summarizes data as requested.
- Reconstructs medical records according to UIHC guidelines.
- Performs audits and prepares special reports as directed.
- Assists in the training and instruction of new employees and Health Information Management students.
Knowledge, Skills, and Abilities
- Knowledge of medical record coding practices, procedures, and reference sources.
- Knowledge of medical terminology.
- Ability to interpret and compare screening guidelines, criteria or definitions.
- Skill in operating office equipment and various software programs.
- 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 it in appropriate format and maintain accurate records.
- 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
- Three years related medical records experience including one year as a Health Information Technician or equivalent experience.