Positions work under general supervision and independently perform professional level health/medical records duties related to residents and/or patients such as, reviewing records for completeness and accuracy; monitoring lengths of stay, severity of illness, and intensity of services to assure appropriate utilization of resources or explain justification for admission, treatment, and length of stay.

Ensures security and confidentiality of resident and/or patient records in order to protect health information as per the Health Insurance Portability and Accountability Act (HIPAA) and other state or federal requirements;

Interpret Revised Code of Washington (RCW) and Code of Federal Regulations (CFR) regarding protection/privacy of patient or resident health records;

Reviews patients' records for completeness and accuracy according to established standards; maintains consistency and accessibility of records;

Collaborates with medical providers or other pertinent staff to resolve clinical documentation inaccuracies, and facilitates improvements and corrections when necessary;

Responds to health/medical record requests from authorized medical providers, staff or third party agents in compliance with applicable policies, laws and requirements;

Performs comprehensive quality assurance and/or compliance audits on patient and/or resident records to ensure compliance with applicable policies, procedures, RCWs and/or CFRs; verifies Advance Beneficiary Notice (ABN) compliance;

Abstracts data using two or more systems and prepares periodic narrative and statistical reports as related to health and/or medical records;

Maintains awareness of current industry trends, best practices and benchmarks in order to provide technical guidance, feedback or training to medical providers and staff;

Represents agency in court or hearing(s) regarding health and/or medical records, as required or requested;

Creates and maintains electronic and physical files;

Identifies and analyzes records systems problems and proposes solutions to management to meet program and system requirements and organizational needs;

May monitor patient’s length of stay, severity of illness, and intensity of services to assure appropriate utilization of resources or explain the justification for admission, treatment, and length of stay;

Designs manual, electronic and/or automated health records filing systems and/or forms to meet specialized requirements; schedules and coordinates the implementation of plans for both standard and specialized systems in consultation with management;

Interact with and assist patients with review of their health records and/or release of their health information;

May lead lower level and/or in-training staff;

Performs other duties as required.

Knowledge of: general health information management (medical records) guidelines, techniques, regulations; medical terminology; policies and procedures related to records management; office management procedures; confidentiality and privacy rules; records retention and destruction guidelines; filing; systems analysis.

Ability to: analyze data for standardization; abstract information required to prepare statistical and other reporting; work effectively with staff, medical providers, and other affected parties; communicate clearly and effectively both orally and in written form; work cooperatively with professional and nonprofessional staff; draw conclusions from data; train technical, professional and other staff; lead other staff.

There may be instances where individual positions must have additional licenses or certification. It is the employer’s responsibility to ensure the appropriate licenses/certifications are obtained for each position.

Persons legally authorized to work in the U.S. under federal law, including Deferred Action for Childhood Arrivals recipients, are eligible for employment unless prohibited by other state or federal law.

Associate’s degree

 

AND

 

At least two years of experience in Health Information Management (medical records) or in a healthcare privacy and/ or compliance office or related area.

 

Combined experience in the above areas may be substituted year for year for the experience desired.

 

Positions generally require current and ongoing accreditation through the American Health Information Management Association (AHIMA) as a Registered Health Information Technician (RHIT) or as a Registered Health Information Administrator (RHIA).

New class. Adopted June 13, 2019, effective July 1, 2019.

Revised Legal Requirements; effective June 6, 2024, due to adopted legislative action.