MEDICAL RECORD SUPERVISOR1204K1 Pay Grade: 22 DEFINITION OF WORK Summary This is supervisory work in coordinating the clerical and technical activities required for medical record administration. Work involves supervising medical record technicians and clerical staff in order to prepare, maintain, analyze, and report medical records for patient admission, diagnosis, treatment, and discharge. Work also includes reviewing the quality of the record keeping process, developing new ways to collect and report medical record statistics, and supervising the preparation of correspondence to release medical record information. Standard Classification Factors Supervision Received - LEVEL C: "Under direction…" Employees at this level usually receive a general outline of the work to be performed and are generally free to develop their own sequences and methods within the scope of established policies. New, unusual, or complex work situations are almost always referred to a superior for advice. Work is periodically checked for progress and conformance to established policies and requirements. Difficulty - LEVEL B: Average… Where the employee is confronted with a variety of duties susceptible to different methods of solution which, in turn, places a correspondingly higher demand upon resourcefulness and concentration. Positions which require the analysis and evaluation of raw data and the rendering of conclusions would, in many instances, fall into this category. Complexity - LEVEL C: Work is of a standardized nature that may involve a variety of duties. Analytical thought becomes more important at this level due to increased data and changing situations. Tasks usually have several steps, some of which may not be directly related. Alternatives may exist for processes or methods to be used in solving problems. Workers at this level exercise a moderate amount of independent judgment. Work is controlled by routine review and reporting to or consultation with supervisors. When guidelines exist at this level, they tend to be more complicated or technical in nature requiring careful interpretation. Consequence of Actions or Decisions - LEVEL D: Consequences of actions or decisions at this level are significant as the work may be rarely if ever reviewed, making errors difficult to detect. Errors may cause major program failure or a high degree of confusion. Injuries to others due to errors are serious or incapacitating or both and costs due to errors are substantial. Contacts - LEVEL B: The purpose of the contact is to plan, coordinate and advise on work efforts, interpret guidelines or instructions, elicit opinions or give guidance on the basis of facts to resolve common issues or problems when the information is not sensitive in nature or the individuals or groups are working toward mutual goals and have basically cooperative attitudes. Well developed communication skills are required. Physical Demands - LEVEL A: The work is predominantly sedentary and requires minimal or negligible physical exertion. The employee is normally seated; however, the nature of the work allows for periods of standing or walking at will. Environmental Conditions - LEVEL A: The work environment involves normal everyday hazards or discomforts typical of offices, meeting and training rooms, or libraries. Comfortable levels of temperature, ventilation, lighting and sound are inherent in the work environment. Exposure to deviations from pleasant environmental conditions is only occasional. The likelihood of injury is remote. Supervision/Leadership - LEVEL D: Involves administrative supervision responsibility. As a "first line supervisor", the primary responsibility involves scheduling, supervising and evaluating employees who perform the same or similar work. Responsible for recommending hiring and disciplinary actions to a higher level of authority. As a "project manager" may direct the activities of project leaders to develop plans and criteria and to evaluate progress and results for one or more projects. Distinguishing Features Differs from the Senior Administrative Assistant class in which the incumbents plan, coordinate, and direct a medical record department in a state institution. EXAMPLES OF WORK PERFORMED Plans, assigns, and supervises work of staff; interviews and trains staff; resolves complaints; develops methods for controlling quality of subordinates' work; prepares documentation for and conducts performance evaluations; and trains medical record technicians and medical record administration students in the assigned area. Reviews in-house chart analyses completed by medical record technicians and clerical staff; ensures medical records are provided in a timely manner upon request; documents the number of incomplete charts and their status. Reports and resolves problems related to medical record entries and re-analyzes records for quality check. Develops new or revised procedures, forms, and reports for accumulating, editing, and disseminating hospital statistics. Supervises staff in preparing correspondence to release medical record information to third parties, gives depositions, and testifies in court regarding the admissibility of medical records as evidence. Reviews the maintenance of indices and registers for continuous quality control and for compliance with federal, state, and agency regulations and third party payers. Performs and oversees laboratory recording, medical transcription, coding, abstracting, and diagnostic group assignment. Oversees timely production and distribution of patient identification Organizes work of medical transcription equipment, determines priorities and movement of transcribed reports to ensure completion within prescribed turnaround time, and compiles and distributes reports. REQUIRED KNOWLEDGE, ABILITIES, AND SKILLS Knowledge *Knowledge of medical record keeping principles and practices. *Knowledge of medical terminology, standard nomenclature, and classification of diagnoses and operations. *Knowledge of anatomy, physiology, and pathology. Knowledge of the principles and practices of supervision. Knowledge of hospital policies governing admissions, discharges, release of information, and of related requirements and accreditation standards. Knowledge of office procedures and statistical techniques for medical record keeping. Abilities *Ability to maintain, review, and analyze medical records. *Ability to formulate and implement plans to carry out program objectives. *Ability to train and evaluate subordinates and to plan, assign, and review their work. *Ability to maintain satisfactory relationships with other employees. *Necessary at Entry MINIMUM REQUIREMENTS: Graduation from a medical records technology program and/or three years of experience in medical recordkeeping and one year of experience in social/human services. Education may be substituted for experience as determined relevant by the agency.
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