Crawford Consulting and Mental Health Services
POSITION TITLE: Medical Records Administrator FLSA: Non-Exempt
REPORTS TO: Vice President, Program Operations DATE: June 05
This position description incorporates the core responsibilities of the job. It is recognized that
other related duties not specifically mentioned might also be performed, and that not all
responsibilities may be carried out depending on operational needs.
Under the general supervision of the VP, Program Operations, the Medical Records Administrator
provides accurate and timely abstracting, analysis, coding, evaluation and reporting of all assigned
client medical records and physician/clinical attestation forms as well as coding related activities.
He/she may refer questionable records for a clinical evaluation; perform utilization review
activities; provide technical supervision to staff.
Documentation Review - Abstract, analyze, code and evaluate client medical records to assure
accurate coding. Maintains regularly scheduled coding productivity reports. Abstract all
documentation relating to the records which are necessary for accurate coding. Analyze
documentation utilizing approved coding guidelines to assign the appropriate codes (i.e. ICD-9-
CM, CPT, DSM III, etc.) in the proper sequence. Evaluates worksheets, coding software entries,
and mainframe information for accuracy. Meets established standards for coding accuracy and
volume within assigned timeframes; reports all coding errors.
Record Review - Refer the necessary medical records for clinical review to assure the appropriate
diagnostic related group and maximum reimbursement according to established guidelines.
Documents questions in a clear, concise manner so all necessary coding and/or reimbursement
information is provided. Demonstrate knowledge and the ability to discuss coding, reimbursement,
and utilization issues to support their code selections. Documents and reports all reimbursement
modifications within established timeframes. Provide consultation on medical record system and
documentation issues to administrative, professional, and clinical staff. Responds appropriately to
requests for consultation, information, and reports. Instructs staff and others, as needed, in medical
records requirements, confidentiality, and related subjects. Instructs staff in the proper procedures
for the inclusion of information into the medical records.
Billing - Review, evaluate, analyze, correct and reports findings of coding, technical, or other
assignment questions. Uses appropriate resources to review, evaluate, analyze and correct all
current coding questions within prescribed timeframes. Reviews, evaluates, analyzes, and corrects
all retrospective coding questions, Medicare data and billing questions within prescribed
timeframes. Submits appropriate rebuttals within prescribed timeframes. Responds to clinical staff
coding changes on current or retrospective accounts within assigned timeframes. Documents
utilization review and notifies third party insurers, when appropriate. Gathers and reports required
information to third party insurers according to established guidelines. Record reviews in treatment
record and on other documents according to established guidelines.
Crawford Consulting and Mental Health Services
Representation - Serve as the agency's custodian of medical records and coordinates all aspects of
the release of medical records information. Determines the appropriateness and validity of requests
for information in accordance with established policies and procedures. Ensures the proper
compliance to the confidentiality requirements of released information in accordance with state and
federal laws. Responds appropriately to court ordered requests for medical records and coordinates
the timely filing of responses.
Professional Development - Maintains knowledge of current agency policies and procedures as
wells as current trends and developments in the field by reading memorandums, notices, books,
journals, etc., and participating in training sessions, meetings, conferences. Applies relevant new
knowledge to performance and other responsibilities. Participates in staff meetings and supervisory
conferences as scheduled to stay up-to-date with changes in policies and programs. Attends internal
and external educational programs and professional meetings as available for continuing
professional education. Reads and evaluates memorandums, notices and professional literature in a
timely manner. Participates in professional continuing education activities. Attends regular
meetings of available and applicable professional organizations. Incorporates knowledge of
pertinent new trends and developments into daily work.
Combination of education and work experience equivalent to an Associates Degree in Business
Administration or Medical records management or related field. Eligibility for certification as a
medical records technician by the American Health Information Management Association,
Three years of experience in a medical records unit which involved the independent coding of
diagnostic data. Excellent problem solving, analytical, organizational and communication skills
required ability to prioritize work according to organizational demands and established timelines.
VP, Program Operations Date
RECEIPT OF POSITION DESCRIPTION: