CLASSIFICATION NO. 537
HEALTH RECORDS SPECIALIST 1
Under general supervision, to perform a variety of complex clerical duties associated with the organization and maintenance of a health records system requiring a standard level of legal protection; to ensure the availability of records and the filing of all client information; to ensure that information is protected and released in accordance with applicable laws, rules and regulations governing confidentiality of health records; to assist in developing and implementing health records policies and procedures; and to do other work as required.
The Health Records Specialist series is used within the Community Health Division of the Department of Human Services which provides both public health and behavioral health services to residents of Clackamas County. Incumbents provide technical and clerical support associated with the processing and maintenance of accurate and legal health records. These health records serve as the basis for professional health care providers to deliver services and protect the financial and legal interests of the provider, facility, and client.
Health Records Specialist 1 is responsible for processing and maintaining health records, performing data entry activities, and responding to requests for health information with a standard level of legal protection.
The Health Records Specialist 1 differs from the Health Records Specialist 2 which processes and maintains health records with an advanced level of legal protection, documentation and reporting requirements and is responsible for processing subpoena and court orders and performing extensive quality assurance activities. It also differs from the Office Specialist classification series which performs a variety of administrative support activities related to reception, word processing, data entry and other general office functions not related to health records.
Duties may include but are not limited to the following:
- Processes internal requests for health records; prepares health records for delivery to medical providers and clinicians; searches for missing records; maintains chart tracking system and forwards health records to appropriate location.
- Organizes and maintains health record filing system that ensures appropriate retrieval and delivery; maintains health record tracking system; resolves concerns regarding efficiency and accuracy of delivery system; audits, repairs and purges health records within established guidelines.
- Processes and files loose documents; reviews health records for filing accuracy; prints dictation and follows up with clinicians to obtain missing dictation, complete information and/or required signatures.
- Performs data entry of health information into supporting databases according to time lines; abstracts data from health records for various reporting requirements.
- Processes external requests for health information; reviews health information requests for validity, completeness and compliance with State and federal law and confidentiality guidelines; determines appropriate health records/documents to release based on applicable laws, rules, regulations and County policy; consults with unit supervisor on complex information requests; determines charges for health record copies; maintains spreadsheet of records released; mails and/or faxes records, letters or forms at the request of CCCH providers and documents appropriately in the record; requests records from outside providers; confers with clinicians, administrative staff, support staff, supervisors, clients, public agencies, attorneys and outside health care providers regarding requests for health information; answers questions about confidentiality, documentation standards and release of health information.
- Assists in educating and training new or existing staff on health records tasks; assists in educating clinicians and other staff in health records issues; resolves technical or procedural problems and issues with records retrieval.
- Assists in developing and implementing procedures to improve quality, content and security of health records within the unit; assists in maintaining health records procedure and policy manuals; makes recommendations for procedural changes as needed.
- Analyzes health records for completeness; follows up to obtain missing reports, complete information and/or required signatures; notifies clinicians or support personnel of deficiencies.
REQUIRED KNOWLEDGE AND SKILLS
Working Knowledge of: Principles and practices of health records management including documentation practices, auditing techniques and filing systems; medical terminology including basic anatomy and physiology; pertinent Federal, State and local laws, rules and regulations applicable to health record confidentiality, release of information and security; concepts and techniques for prioritizing and organizing work; office practices and procedures; basic English, spelling, grammar and punctuation.
Skill to: Independently, accurately and effectively perform assigned tasks and duties following established procedures and policies with adherence to time lines; correctly interpret and apply laws, rules, and regulations governing health records, confidentiality and security; organize and maintain an accurate health records filing system using alpha and numeric (terminal digit) filing; perform detailed record maintenance, retrieval and filing; compute charges due according to billing schedule; communicate effectively, both orally and in writing; operate office equipment including personal computers, photocopiers, printers and fax machines; use relevant software programs including specialized databases; maintain effective working relationships with County staff, health professionals, clients, patients, attorneys and public agencies.
Must successfully pass a criminal history check which may include national or state fingerprint records check.
Driving may be necessary for County business. For position(s) with occasional/incidental driving, incumbents must possess a valid driver's license. Accommodation requests for an acceptable alternative method of transportation will be reviewed on an individual basis in compliance with State and Federal legislation. For position(s) with regular driving, incumbent(s) must also possess and maintain an acceptable driving record throughout the course of employment.
MINIMUM RECRUITING STANDARDS
Any satisfactory combination of experience and training that demonstrates possession of the required knowledge and skills.