Health Records Specialist

Class Characteristics

Under general supervision, to perform a variety of complex administrative duties associated with the organization, maintenance and integrity of a health records system requiring a standard level of legal protection; to ensure the availability of records and the organization of patient information; to protect and release information in accordance with applicable laws, rules and regulations governing confidentiality of health records; and to do other work as required.

Distinguishing Characteristics

The Health Records Specialist classification series is used within the Health Centers Division of Health, Housing & Human Services (H3S) which provides health services to residents of Clackamas County.

The Health Records Specialist is responsible for processing and maintaining accurate and legal health records which provide real-time availability of quality information for professional health care providers to deliver services and protect the financial and legal interests of the provider, facility, and patient. Incumbents perform data entry and scanning activities, maintain data integrity, confidentiality, and security, and respond to requests for health information with a standard level of legal protection. The Health Records Specialist provides customer service both internally and externally.

The Health Records Specialist differs from the Health Records Specialist, Senior which processes health records requests requiring an additional level of legal protection, such as subpoenas and court orders, and have responsibilities for training and quality assurance of program-wide health records activities. It differs from the Office Specialist classification series which performs a variety of moderately difficult administrative support activities according to generally established guidelines, regulations or instructions but not related to health records.

Typical Tasks

Duties may include but are not limited to the following:

1. Prepares, scans, indexes, abstracts, and processes health records containing protected health information through electronic and other health record systems for immediate access by medical providers, clinicians, dental providers, and clinic office support staff; processes internal requests for health, behavior health, and dental records, and dental referrals; searches for missing records; forwards health records to appropriate location.
2. Receives, tracks and processes external requests for a variety of health information with standard level of protections; verifies and reviews health information requests and authorization forms for validity, completeness and compliance with State and Federal law and confidentiality guidelines; determines and compiles appropriate health records and documents to release based on review and interpretation of applicable and evolving laws, rules, regulations and County policy; consults with supervisor on complex information requests; calculates charges for health record copies; mails, emails and/or faxes records, and documents actions appropriately in the record; requests records from and provides records to outside providers; confers with clinicians, administrative and support staff, supervisors, patients, public agencies, attorneys and outside health care providers regarding requests for health information.
3. Provides assistance and information to staff, patients, and third parties such as other clinics, insurance companies, government agencies, and law firms via phone and email; explains how to obtain records; provides status on records requests; provides timeframe for when requested records are expected to be received.
4. Answers questions about confidentiality, documentation standards, procedures, and release of health information; assists in educating and training new Health Records staff on health records tasks; assists in educating clinicians and other internal staff regarding health records issues; resolves issues with records retrieval and in locating information.
5. Reviews health records for completeness; searches for missing records; follows up with clinicians and others to obtain missing documentation, information or required signatures; performs data entry of health information into supporting databases according to timelines; extracts and compiles medical care and other data from health records for various inquiries and reporting requirements; navigates among several specialized, complex systems; merges duplicate registrations.
6. Assists in developing and implementing procedures to improve quality, content and security of health records; assists in maintaining health records procedure manuals; makes recommendations for procedural changes as needed; audits charts and internal processes as requested.

Required Knowledge and Skills

Working knowledge of: Electronic Health Records systems; principles and practices of health records management including documentation practices, auditing techniques and filing systems; medical terminology including basic anatomy and physiology; current, relevant 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; basic math.

Skill to: Independently, accurately and effectively perform assigned tasks and duties following established procedures and policies with adherence to timelines; correctly research and interpret and apply laws, rules, and regulations governing health records, release of health information, confidentiality and security; organize and maintain an accurate health records filing system; perform detailed record research, maintenance, retrieval and filing utilizing multiple software programs; compute charges due according to billing schedule; communicate effectively, both orally and in writing; operate office equipment including computers, printers and fax machines; use variety of software programs including spreadsheets and specialized databases; maintain effective working relationships with County staff, health professionals, patients, attorneys, other agencies, and the public.

Minimum Qualifications

 

Minimum qualifications are used as a guide for establishing the minimum experience, education, licensure, and/or certifications required for employment in the classification. The following minimum qualifications are established for this classification. Additional minimum qualifications and special conditions may apply to a specific position within this classification and will be stated on the job announcement.

Experience: A minimum of one (1) year of related experience that would provide the required knowledge and skills to perform the responsibilities of this position.

Licenses/Certifications: None required.

Pre-Employment Requirements

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.

Post-Employment Requirements

Some positions require possession of or the ability to obtain Notary Public Certification within six months of hire.

Edited: 3/24

Classification No. 537
Established: 10/08
Revised: 1/19
Retitled: 3/24
FLSA: Non-Exempt
EEO: 6