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Medical Record Director (1864)

Medical Record Director

California State Personnel Board Specification

  • Schematic Code: CW30
  • Class Code: 1864
  • Established: 08/03/1951
  • Revised: 09/20/2006
  • Title Changed: 06/03/1987

Definition

Under general direction plans, develops, and manages a comprehensive health records system of administrative and clinical data in the Medical Records section of each State hospital, licensed care facility, or correctional facility; manages and directs a staff and oversees a health record system that meets medical, administrative, legal, ethical regulatory agency, and facility requirements; and does other related work.

Typical Tasks

Plans, develops, and directs a health records system to meet the facility's goals, standards of accreditation, third-party payor, and regulatory agency requirements; develops and implements policies and procedures for information handling and dissemination in accordance with professional ethics and in conformity with applicable Federal, State, and local statutes and regulations; develops methods for and conducts evaluation of health record content; collects and analyzes health record data for statistical, reimbursement, and patient care evaluation; advises and assists with implementation relative to health record policies; complies and/or assists in maintaining a complete computerized health record system; manages health record data to link clinical data to reimbursement; is the resource person for Federal and State regulations, Medicare, Medi-Cal, and other third-party payor provider reviews, and utilization review of program requirements; liaison between the facility and programs; serves as an integral part of the facility-wide quality assurance program; coordinates the activities of the utilization review program and medical record committee; serves as a member of other clinical and administrative committees; develops in-service educational materials and conducts instructional programs for health record, administrative, and clinical staff; assists in scientific research and compiles statistical analyses; and develops and maintains health data retention schedules and retrieval systems.

Minimum Qualifications

Either I

 

Registration by the American Medical Record Association as a Registered Record Administrator or eligibility for examination for registration. (Applicants who are not Registered Record Administrators will be admitted to the examination, but they must secure the certificate of registration, or submit proof of eligibility for examination for registration as evidenced by a statement from the Association before they will be considered eligible for appointment.) and

 

Two years of experience in a medical records office of an approved hospital which must have involved the supervision of medical records personnel or consultation to the clinical staff on the quality of medical records.

Or II

 

Certification by the American Medical Record Association as an Accredited Record Technician or eligibility for examination for accreditation. (Applicants who are not Accredited Record Technicians will be admitted to the examination, but they must secure the certificate of accreditation, or submit proof of eligibility for examination for accreditation as evidenced by a statement from the Association before they will be considered eligible for appointment.) and

 

Experience: Four years of experience in a medical records office of an approved hospital which must have involved the supervision of medical records personnel or consultation to the clinical staff on the quality of medical records.

Or III

 

Certification by the American Medical Record Association as an Accredited Record Technician or eligibility for examination for accreditation. (Applicants who are not Accredited Record Technicians will be admitted to the examination, but they must secure the certificate of accreditation, or submit proof of eligibility for examination for accreditation, as evidenced by a statement from the Association before they will be considered eligible for appointment.) and

 

Experience: Two years of experience performing the duties of a Health Records Technician III in the California state service.

Knowledge and Abilities

Knowledge of: Principles, methods, procedures, and current trends in health information systems and management of health record department; accreditation, certification, and licensing standards; quality assurance standards and techniques; qualitative and quantitative analysis of health records; techniques of word processing and transcription; diagnostic nomenclatures, classification systems, data abstracting, and retrieval techniques; data processing and computer systems; clinical and legal terminology; health records systems design and form control; current trends of health records data management and linkage of clinical data to reimbursement; organization and management concepts and functions; and a supervisor's responsibility for promoting equal opportunity in hiring and employee development and promotion, and for maintaining a work environment that is free of discrimination and harassment.

 

Ability to: Plan and direct the work of others; analyze policies, procedures, laws and regulations, and apply state-of-the-art knowledge to determine an effective course of action; communicate effectively; coordinate with clinical and administrative staff; develop data display techniques and research methodologies; and effectively promote equal opportunity in employment and maintain a work environment that is free of discrimination and harassment.

  Updated: 6/3/2012
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