Basic Purpose Positions in this job family are assigned responsibilities related to preparing, classifying and abstracting medical reports in the medical records unit. Typical Functions The functions performed in this job family will vary by level, unit and organization, but may include the following: Reviews medical records for completeness and accuracy and refers incomplete or inaccurate reports to appropriate staff for correction. Prepares statistical, case and other types of reports. Prepares materials and forms and gathers all pertinent information and data for admissions and discharges. Ensures all data is properly coded. Abstracts charts and other patient data in order to respond to requests for information on patients; may make determinations on what materials can legally be released. Assists in the development of medical records policies and procedures. Reviews existing policies and procedures to ensure they are in compliance with federal and state laws and agency rules, regulations and policies. Insures the security and confidentiality of patient medical records. May supply requested information to courts and other judicial inquires. Level Descriptor Levels are distinguished based on the complexity of assigned duties, the level of expertise required for completion of work assignments, and the responsibility assigned for the supervision of others. This is the leadership level where employees are assigned responsibilities involving the supervision of technical or clerical personnel in a medical records unit.
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Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
Number of Employees
11-50 employees