CS-214 1. Position Code REV 8/2007 MEDRSV2A05N State of Michigan Civil Service Commission Capitol Commons Center, P.O. Box 30002 Lansing, MI 48909 Federal privacy laws and/or state confidentiality requirements protect POSITION DESCRIPTION a portion of this information.
This form is to be completed by the person that occupies the position being described and reviewed by the supervisor and appointing authority to ensure its accuracy. It is important that each of the parties sign and date the form. If the position is vacant, the supervisor and appointing authority should complete the form. This form will serve as the official classification document of record for this position. Please take the time to complete this form as accurately as you can since the information in this form is used to determine the proper classification of the position. THE SUPERVISOR AND/OR APPOINTING AUTHORITY SHOULD COMPLETE THIS PAGE.
2. Employee’s Name (Last, First, M.I.) 8. Department/Agency Vacant Community Health
3. Employee Identification Number 9. Bureau (Institution, Board, or Commission) Hospitals and Centers
4. Civil Service Classification of Position 10. Division Medical Records Examiner Supervisor-2 Center for Forensic Psychiatry
5. Working Title of Position (What the agency titles the 11. Section position) Information Services Medial Record Director
6. Name and Classification of Direct Supervisor 12. Unit Thomas Shazer, Psy.D., Forensic Psych. Manager-2 Medical Records
7. Name and Classification of Next Higher Level Supervisor 13. Work Location (City and Address)/Hours of Work Carol Holden, Ph.D., Senior Executive Hospital Dir. 18 8303 Platt Rd. Saline, MI 48160 Monday - Friday, 8:00 a.m. - 4:30 p.m 14. General Summary of Function/Purpose of Position This position is responsible for processing, maintaining and securing all written and/or electronic health information for an approximately 210-240 bed inpatient psychiatric facility which also conducts approximately 3,000 evaluations each year, by ensuring that the information contained in the record is audited for completeness and accuracy, that it is accessible only to authorized personnel, and that it is released only under legally acceptable circumstances. This position plans, develops, organizes, implements, evaluates, and supervises the Health Information Department in accordance with established policies and procedures, including ensuring compliance with Joint Commission and CMS standards as well as other Federal and State guidelines. Also, this position functions as the agency’s HIPAA Privacy Officer, and serves on various committees and workgroups. This position participates as a key member of the team which oversees the site-level operational use of enterprise- level electronic health record systems
For Civil Service Use Only
15. Please describe your assigned duties, percent of time spent performing each duty, and explain what is done
Page 1 to complete each duty. List your duties in the order of importance, from most important to least important. The total percentage of all duties performed must equal 100 percent.
Duty 1 General Summary of Duty 1 % of Time 45 Plans, develops, organizes, implements, evaluates, and supervises the Health Information Department in accordance with established policies and procedures, including ensuring compliance with Joint Commission and CMS standards as well as Federal and State guidelines.
Individual tasks related to the duty. Oversees the use of health information systems in accordance with departmental, JC and CMS standards Assesses the adequacy of health information practices to ensure conformance with policies, rules and regulations Maintains records, prepares reports and composes correspondence relative to work Ensures timely transcription of clinical documents Responds to requests from individuals, agencies, hospitals, and/ or courts for health information in accordance with statutes and departmental regulations regarding confidential information Explains rules, regulations, policies, and procedures to staff as needed to ensure compliance with health information requirements Ensures preparation of clinical documents relative to admission, transfer, discharge or placement of patients Develops and updates policies and procedures relating to health information practices Represents the facility in court regarding health information production, use and authenticity Oversees the processing of clinical and legal documents Oversees the use of various health information management systems which are used to collect, classify, store, or analyze information Reviews/audits records for completeness, accuracy, and compliance with regulations Protects the privacy of health information to ensure that confidentiality is maintained Abstracts information from records as authorized/required for insurance companies, Medicare, etc. Performs other related duties as assigned
Duty 2 General Summary of Duty 2 % of Time 40 Supervision of Health Information Department.
Page 2 Individual tasks related to the duty. Coordinates staff activities by scheduling work assignments, setting priorities and directing the work of subordinate staff Evaluates and verifies employee performance through the review of completed work assignments and work techniques Approves or denies leave requests Issues corrective and/or disciplinary actions to subordinate staff Selects and assigns staff Identifies staff development and training needs and ensures that training is obtained
Page 3 Duty 3 General Summary of Duty 3 % of Time 15 Other duties as assigned
Individual tasks related to the duty. Serves as the agency’s HIPAA Privacy Officer - advises senior administration on requirements of the Privacy Rule, conducts investigations relative to alleged PHI privacy breaches, etc. Serves as member of the agency’s EHR implementation team Attends training and meetings relative to the development of the EHR Develops and conducts staff training on the use of EHR Assigned to various committees
Duty 4 General Summary of Duty 4 % of Time
Individual tasks related to the duty.
Page 4 Duty 5 General Summary of Duty 5 % of Time
Individual tasks related to the duty.
Duty 6 General Summary of Duty 6 % of Time
Individual tasks related to the duty.
Page 5 16. Describe the types of decisions you make independently in your position and tell who and/or what is affected by those decisions. Use additional sheets, if necessary. Decisions relative to oversight of a medical record system, so as to ensure compliance with departmental, state/federal and accreditation body standards. The department and agency are affected insofar as failure to comply with standards could jeopardize our JC/CMS accreditation, could result in the CFP being fined, and could result in delay or denial of reimbursement claims.
Decisions relative to supervision of Health Information Department, including decisions about work assignments. These decisions affect Health Information Department staff, as well as clinical staff who rely on the Health Information Department to process health information.
17. Describe the types of decisions that require your supervisor’s review.
Decisions that would impact the operations of various disciplines and decisions that are out of the scope of department policies and procedures.
18. What kind of physical effort do you use in your position? What environmental conditions are you physically exposed to in your position? Indicate the amount of time and intensity of each activity and condition. Refer to instructions on page 2. Standard office conditions with moderate degree of risk as there is occasional contact with inpatients who are housed in our secured facility. Daily walking, climbing stairs, bending, reaching, lifting. Daily sitting at desk, using keyboards, mice and scanners, reading text on monitors
19. List the names and classification titles of classified employees whom you immediately supervise or oversee on a full-time, on-going basis. (If more than 10, list only classification titles and the number of employees in each classification.)
NAME CLASS TITLE NAME CLASS TITLE Ruth Frazier WPA 8 Judy Johnston MRE 10 Cleta Williams WPA 7 Vacant WPA 7 Katie Oliver WPA 7 Elizabeth Edwards WPA 7 Kimberly Meyer MRE 10 20. My responsibility for the above-listed employees includes the following (check as many as apply):
X Complete and sign service ratings. X Assign work. X Provide formal written counseling. X Approve work. X Approve leave requests. X Review work. X Approve time and attendance. X Provide guidance on work methods. X Orally reprimand. X Train employees in the work.
Page 6 21. I certify that the above answers are my own and are accurate and complete.
Signature Date
NOTE: Make a copy of this form for your records.
Page 7 TO BE COMPLETED BY DIRECT SUPERVISOR 22. Do you agree with the responses from the employee for Items 1 through 20? If not, which items do you disagree with and why?
23. What are the essential duties of this position? This position oversees the handling of patient/defendant data by staff of the CFP’s Health Information Department, which requires knowledge of standards for handling health information drawn from Michigan’s Mental Health Code and Administrative Rules, HIPAA, and JC & CMS regulations. In particular the person in this position is familiar with the use of the DCH Electronic Health Record (EMBRS) and other clinical informatics systems, oversees a designated set of EMBRS operations, and provides technical advice/consultation to clinical and administrative staff who use EMBRS. The person in this position also serves as a general resource for all other CFP staff who are involved in handling patient/defendant data, by providing consultation about health information questions and responding to potential patient information privacy breaches, in the role of the CFP’s HIPAA Privacy Officer. This position supervises Health Information Department staff and involves assigning work, reviewing performance, conducting any corrective action which might be needed.
24. Indicate specifically how the position’s duties and responsibilities have changed since the position was last reviewed.
Some specific duties of this position have evolved over time as the CFP has obtained JC accreditation and CMS Certification, and with the advent of HIPAA (e.g., prior to HIPAA it did not involve responsibilities associated with the Privacy Officer role). More significant and more recent changes are associated with the implementation of EMBRS, ongoing at the time of this writing; this position now requires a familiarity with electronic data systems generally, and with the work processes associated with an Electronic Health Record, which were simply not job requirements previously.
25. What is the function of the work area and how does this position fit into that function?
The Health Information Department is responsible for processing, maintaining and securing all written and/or electronic health information for an approximately 210-240 bed inpatient psychiatric facility which also conducts approximately 3,000 evaluations each year, by ensuring that the information contained in the record is audited for completeness and accuracy, that it is accessible only to authorized personnel, and that it is released only under legally acceptable circumstances. This position plans, develops, organizes, implements, evaluates, and supervises the Health Information Department in accordance with established policies and procedures, including ensuring compliance with Joint Commission and CMS standards as well as other Federal and State guidelines.
Page 8 26. In your opinion, what are the minimum education and experience qualifications needed to perform the essential functions of this position.
EDUCATION: Possession of an associate’s degree in health information or medical record technology.
EXPERIENCE: Four years of experience equivalent to a Medical Record Examiner, including two years equivalent to a Medical Record Examiner E10 or one year equivalent to a Medical Record Examiner Supervisor 11; or, five years of administrative support, supervisor experience maintaining medical record systems, monitoring the quality of medical record keeping and responding to requests for medical record information.
KNOWLEDGE, SKILLS, AND ABILITIES:
CERTIFICATES, LICENSES, REGISTRATIONS: Certification by the American Health Information Management Association as a Registered Health Information Technician or Registered Health Information Administrator.
NOTE: Civil Service approval of this position does not constitute agreement with or acceptance of the desirable qualifications for this position. 27. I certify that the information presented in this position description provides a complete and accurate depiction of the duties and responsibilities assigned to this position.
Supervisor’s Signature Date TO BE FILLED OUT BY APPOINTING AUTHORITY 28. Indicate any exceptions or additions to the statements of the employee(s) or supervisor.
29. I certify that the entries on these pages are accurate and complete.
Appointing Authority’s Signature Date
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