CLASSIFICATION NO. 538
HEALTH RECORDS SPECIALIST 2
Under general supervision, to perform a variety of complex clerical duties associated with the organization and maintenance of a health records system requiring an advanced level of legal protection, documentation, and reporting requirements; 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 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.
The Health Records Specialist 2 is responsible for processing subpoenas and Court orders, performing extensive quality assurance activities and responding to requests for health information with special protection requirements under State and Federal laws, rules and regulations.
The Health Records Specialist 2 differs from the Health Records Specialist 1 which responds to requests for health information with standard special protection requirements and performs limited quality assurance activities.
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 records delivery system to outlying clinics 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 and facility records within established guidelines.
- Processes and files loose documents; reviews health records for filing accuracy; follows up with clinicians to obtain missing documentation, complete information and/or required signatures.
- Performs data entry of health information into the health record; opens and closes client records in the electronic health record; updates and maintains unit, sub unit, and treatment session and clinician assignments in the electronic health record.
- May be responsible for data management and reporting; run reports and provide required data to State and other agencies.
- Assists in educating and training new or existing staff on health records tasks; clinicians and other staff regarding appropriate use of unit, sub unit, or treatment session codes and corresponding documentation requirements; assists in training staff involved in filing and retrieving client records; resolves technical or procedural problems and issues with records retrieval.
- Processes external requests for health information including subpoenas; reviews subpoenas and other 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 database 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 and maintains database of records received; confers with clinicians, administrative staff, support staff, supervisors, clients, public agencies, attorneys and outside health care providers regarding subpoenas and other requests for health information; answers questions about confidentiality, documentation standards and release of health information.
- Assists in developing and implementing policies and 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, accuracy and appropriate coding; follows up to obtain missing reports, complete information and/or required signatures; notifies clinicians or support personnel of deficiencies.
- Performs extensive quality assurance activities and corrections on all records for compliance with State of Oregon Client Process Monitoring System reporting requirements; assists in coordinating data for State reporting requirements.
REQUIRED KNOWLEDGE AND SKILLS
Working knowledge of: Principles and practices of health records management including documentation practices, auditing techniques, coding systems 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 cooperative 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.