This is the expert or supervisory level of the series. Positions are responsible for maintaining and/or updating of health and/or medical record related retention schedules; coordinating, retrieving and reviewing health/medical records information for and responding to medically related public record requests; coordinating the day-to-day delivery, distribution, access, maintenance and retention of manual and/or electronic health/medical records or forms.

Under general direction, independently performs one or more of the following:

 

• Supervision of staff performing professional level duties related to residents and/or patients health/medical records and/or medical diagnostic and procedural coding; 

 

• As an expert, provides determinations on responses to health/medical related public records requests and litigation discovery. Consults with management to provide guidance on complex health/medical records related issues such as medical related financial records, billing for services or complex guidelines related to Medicare/Medicaid or other insurance; and is responsible for resolving the most complex, critical, and/or precedent-setting issues that arise.

Identifies and develops employee training needs and opportunities for improvement in staff performance and processes based on analyzed trends, tracked metrics and benchmarks, and organizational alignment with industry best practices;

Receives medically related public records requests and assists requestors in defining the scope of the requested information, identifies records responsive to requestors, and retains records related to requests in accordance with established records retention statutes;

As expert consultant to management, provides guidance on complex health and/or medical records related issues;


Develops, reviews and updates records retention and essential records schedules to ensure conformance with state, federal and agency or institution standards related to health and/or medical records;

Determines, gathers and reviews information required for regulated and/or agency reporting purposes for resident and/or patient related health/medical record data;

In consultation with management, develops policies and/or procedures for health and/or medical record quality assurance and audit review processes within the unit, department or agency and coordinates or distribution of such materials;

Represents agency or department in court or other similar matters as an expert in the field of health and medical records requirements;

Uses combination of Health Information Management (HIM) skills and expertise to conduct concurrent and/or retrospective reviews of health records to ensure compliance with State and Federal regulations;

Resolves problems related to health/medical records by devising solutions;

Designs and develops training materials related to health and/or medical records retention, quality assurance and audit review processes for subordinate and other relevant staff;

May perform specialized records or information systems studies;

Conducts review of medical coding issues, gather data, identify trends, and make recommendations on process and/or policy development and communications, outreach and education for medical diagnostic coding;

May perform data entry and abstract pertinent data from medical records to ensure data integrity and optimal reimbursement;

Audits medical records to ensure accurate diagnostic codes and services to assist in recouping or adjusting health care payments and to follow federal mandates and compliance;

Performs other duties as required.

Knowledge of: general health information management (medical records) guidelines, procedures, techniques, regulations and medical terminology; office management procedures; confidentiality and privacy rules; agency policies and procedures; systems analysis; State records management system procedures; laws related to records retention and protection;

Ability to: work professionally and courteously with all levels of management and staff; analyze paperwork and/or data for standardization; abstract information required to prepare statistical and other reporting; work effectively with program staff, medical providers, and other affected parties; communicate clearly and effectively both orally and in written form; draw conclusions from data; train technical, professional and other staff; supervise and mentor 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.

Bachelor’s Degree in health information management, business administration, or related field;

 

AND

 

Three years of experience in a Health Information Management (medical records) office, office management, healthcare privacy office, compliance office or closely related area;

 

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).

 

For positions supervising medical coding staff, a Certified Professional Coder (CPC) ^® certification, or equivalent, may be required.

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

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