Class Description and Minimum Qualifications for G3D -Medical Records Technician

Class Description

Valid as of: July 2018

This class series uses three levels in the Administrative Services and Related Occupational Group and describes work in the maintenance of medical records. Work involves translating narrative descriptions of treatment into uniform numerical designations, assembling charts and checking them for completeness, and releasing of medical records information. Maintenance of records includes storage, retrieval, timely destruction, and security. It is the translation of treatment narratives into uniform numerical designations and release of medical information processes that separate this class from other office support classes.

MEDICAL RECORDS TECHNICIAN I G3D1XX

Concept of Class

This class describes the first level of the medical records technician. Work in this class includes assembling charts and census counts; reviewing records for completeness, conformance to legal requirements, and/or eligibility for a registry; notifying the originator of any deficiencies; classifying diagnoses and procedures according to the uniform coding system; computing numbers for reports; and, determining the validity of authorizations for release of medical information. Positions in this class also perform related support work, such as arranging travel for clinicians or clients, scheduling examinations, filling out billing paperwork, medical transcription, and data entry.

Factors

Allocation must be based on meeting all of the three factors as described below.

Decision Making -- The decisions regularly made are at the defined level, as described here. Within limits prescribed by the operation, choices involve selecting alternatives that affect the manner and speed with which tasks are carried out. These choices do not affect the standards or results of the operation itself because there is typically only one correct way to carry out the operation. For example, within the agency's classification system, maintenance procedures, and quality standards, positions in this class review the record for completeness and the proper sequence of documents, assign and sequence the proper classifications, and correct errors in
compiled data or classifications. These alternative include independent choice of such things as priority and personal preference for organizing and processing the work, proper tools or equipment, speed, and appropriate steps in the operation to apply. For example, positions in this class determine the priority of tasks and may develop tracking systems. By nature, the data needed to make decisions can be numerous but are clear and understandable so logic is needed to apply the prescribed alternative. For example, a position uses logic in determining the most efficient method to gather data from another agency based on location, size, and previous cooperation on requests. Positions can be taught what to do to carry out assignments and any deviation in the manner in which the work is performed does not change the end result of the operation. In this class, regardless of the personal methods used to complete tasks, the end result remains the maintenance of accurate records and data and the timely processing of work and requests.

Complexity -- The nature of, and need for, analysis and judgment is prescribed, as defined here. Positions apply established, standard guidelines which cover work situations and alternatives. Action taken is based on learned, specific guidelines that permit little deviation or change as the task is repeated. Positions in this class follow uniform coding system manuals, instructions, established forms, the established standards and sequence of documents, policy and regulations on the release of medical information, billing rates, and software manuals and procedures. Any alternatives to choose from are clearly right or wrong at each step. For example, if procedure is not followed in entering data, an error results. The sequence of documents in the file is either correct or incorrect. 

OR 

The nature of, and need for, analysis and judgment is patterned, as defined here. Positions study information on narratives, notes, lab reports, and file summaries to determine what it means and how it fits together in order to get practical solutions in the form of proper classifications. Guidelines in the form of uniform coding systems and manuals, registry or project policy and procedure, quality standards, and policy and regulations on release of information exist for most situations. Judgment is needed in locating and selecting the most appropriate of these guidelines which may change for varying circumstances as the task is repeated. For example, positions may choose from several proper classifications depending on the type of registry or may need to amend classifications for the agency's type of client. This selection and interpretation of guidelines involves choosing from alternatives where all are correct but one is better than another depending on the given
circumstances of the situation. For example, positions in this class determine the validity of requests for release of medical information, including which authorizations are necessary and if additional information is needed, which varies depending on the requestor and the type of requests, and the nature of the information requested.

Line/Staff Authority -- The direct field of influence the work of a position has on the organization is as an individual contributor. The individual contributor may explain work processes and train others. The individual contributor may serve as a resource or guide by advising others on how to use processes within a system or as a member of a collaborative problem-solving team. This level may include positions performing supervisory elements that do not fully meet the criteria for the next level in this factor.

MEDICAL RECORDS TECHNICIAN II G3D2XX

Concept of Class

This class describes the second level of the medical records technician. In addition to the duties and responsibilities in the Medical Records Technician I class, positions in this class assist in maintaining the quality of an agency's medical records classification system and release of medical information. Work includes determining operating procedures, developing data collection forms, and monitoring the quality of the agency's treatment records. The factors in this class differ from those in the Medical Records Technician I class on Decision Making and possibly Complexity.

Factors

Allocation must be based on meeting all of the three factors as described below.

Decision Making -- The decisions regularly made are at the operational level, as described here. Within limits set by the specific process, choices involve deciding what operation is required to carry out the process. This includes determining how the operation will be completed. For example, within the medical records process, positions in this class develop procedures and forms for the consistent maintenance and security of records, monitoring quality through periodic internal reviews of a sample of records, and the timely collection of data. By nature, data needed to make decisions are numerous and variable so reasoning is needed to develop the practical course of action within the established process. Choices are within a range of specified, acceptable standards, alternatives, and technical practices. For
example, within standards, uniform coding systems, and policies and processes, positions in this class are responsible for the practical aspects of treatment records classification, storage, retrieval and release, tracking, and security in a facility.

Complexity -- The nature of, and need for, analysis and judgment is patterned, as described here. Positions study information on narratives, notes, lab reports, and file summaries to determine what it means and how it fits together in order to get practical solutions in the form of proper classifications. Guidelines in the form of uniform coding systems and manuals, registry or project policy and procedure, quality standards, and policy and regulations on release of information exist for most situations. Judgment is needed in locating and selecting the most appropriate of these guidelines which may change for varying circumstances as the task is repeated. For example, using legal, ethical, accreditation, and agency records requirements, positions determine if a chart is complete in situations where there are variances in the data. As another example, positions may amend the classifications for the agency's type of client. This selection and interpretation of guidelines involves choosing from alternatives where all are correct but one is better than another depending on the given circumstances of the situation. For example, positions in this class determine the validity of requests for release of medical information, including which authorizations are necessary and if additional information is needed, which varies depending on the requestor and the type of requests, and the nature of the information requested.

Line/Staff Authority -- The direct field of influence the work of a position has on the organization is as an individual contributor. The individual contributor may explain work processes and train others. The individual contributor may serve as a resource or guide by advising others on how to use processes within a system or as a member of a collaborative problem-solving team. This level may include positions performing supervisory elements that do not fully meet the criteria for the next level

MEDICAL RECORDS TECHNICIAN III G3D3XX

Concept of Class

This class describes the work leader or unit supervisor. In addition to the duties and responsibilities of a medical records technician, positions in this class oversee the work product of other positions. The factors in this class differ from those in the Medical Records Technician II class on Line/Staff Authority.

Factors

Allocation must be based on meeting all of the three factors as described below.

Decision Making -- The decisions regularly made are at the operational level, as described here. Within limits set by the specific process, choices involve deciding what operation is required to carry out the process. This includes determining how the operation will be completed. For example, positions in this class are responsible for the daily work flow of the agency's medical records unit, including developing procedures and forms for the consistent maintenance and security of records, monitoring of quality through periodic internal reviews of a sample of records, and the timely collection of data. By nature, data needed to make decisions are numerous and variable so reasoning is needed to develop the practical course of action within the established process. Choices are within a range of specified, acceptable standards, alternatives, and technical practices. For example, within standards, uniform coding systems, and policies and processes, positions in this class are responsible for the practical aspects of records classification, storage, retrieval and release, tracking, and security in a facility.

Complexity -- The nature of, and need for, analysis and judgment is patterned, as described here. Positions study information on work flow activities, agency policies, medical records standards to determine what it means and how it fits together in order to get practical solutions in the form of records procedures for operating a medical records unit or registry. Guidelines in the form of uniform coding systems and standards, registry or project policy and procedure, quality standards,
and policy and regulations on release of information exist for most situations. Judgment is needed in locating and selecting the most appropriate of these guidelines which may change for varying circumstances as the task is repeated. For example, using legal, ethical, accreditation, and agency records requirements, positions may need to amend the classifications for the agency's type of client. This selection and interpretation of guidelines involves choosing from alternatives
where all are correct but one is better than another depending on the given circumstances of the situation. For example, positions in this class determine the validity of requests for release of medical information, including which authorizations are necessary and if additional information is needed, which varies depending on the requestor and the type of requests, and the nature of the information requested.

Line/Staff Authority -- The direct field of influence the work of a position has on the organization is as a work leader. The work leader is partially accountable for the work product of two or more full-time equivalent positions, including timeliness, correctness, and soundness. At least one of the subordinate positions must be in the same series or at a comparable conceptual level. Typical elements of direct control over other positions by a work leader include assigning tasks, monitoring progress and work flow, checking the product, scheduling work, and establishing work standards. The work leader provides input into supervisory decisions made at higher levels, including signing leave requests and approving work hours.

OR

The direct field of influence the work of a position has on the organization is as a unit supervisor. The unit supervisor is accountable, including signature authority, for actions and decisions that directly impact the pay, status, and tenure of three or more full-time equivalent positions. At least one of the subordinate positions must be in the same series or at a comparable conceptual level. The elements of formal supervision must include providing documentation to support recommended corrective and disciplinary actions, signing performance plans and appraisals, and resolving informal grievances. Positions start the hiring process, interview applicants, and recommend hire, promotion, or transfer.

Entrance Requirements

Minimum entry requirements and general competencies for classes in this series are contained in the State of Colorado Department of Personnel web site. 

For purposes of the Americans with Disabilities Act, the essential functions of specific positions are identified in the position description questionnaires and job analyses.

History of Changes Made to Class Description

The​ ​following​ ​is​ ​a​ ​summary​ ​of​ ​changes​ ​made​ ​to​ ​this​ ​class description.

July 1, 2018

Effective 7/1/18: Update the Class Code of G3D1TX to G3D1XX per administrative updates.

June 30, 2015

Updated and removed the purpose of contact 6.30.2015

June 1, 1994

Effective 6/1/94 (KKF). Change in the Line/Staff Authority factor for the Medical Records Technician III. Published proposed 5/16/94.

September 1, 1993

Effective 9/1/93 (KKF). Job Evaluation System Revision project. Published as proposed 4/9/93. Revised 7/1/83. Revised minimum requirements.

July 1, 1978

Revised 7/1/78. Revised minimum requirements for Medical Records Technician I and II
(5718-19). Created 1/1/75.

Summary of Factor Ratings

Minimum Qualifications

Valid as of: December 6, 2023

This​ ​document​ ​includes​ ​the​ ​following​ ​levels:
 

MEDICAL RECORDS TECHNICIAN I (G3D1XX)

Experience Only:

One (1) year of relevant experience in an occupation related to the work assigned to this position

OR

Education and Experience:

A combination of related education, certification, and/or relevant experience in an occupation related to the work assigned equal to one (1) year
 

MEDICAL RECORDS TECHNICIAN II (G3D2XX)

Experience Only:

Two (2) years of relevant experience in an occupation related to the work assigned to this position

OR

Education and Experience:

A combination of related education, certification, and/or relevant experience in an occupation related to the work assigned equal to two (2) years

MEDICAL RECORDS TECHNICIAN III (G3D3XX)

Experience Only:

Three (3) years of relevant experience in an occupation related to the work assigned to this position

OR

Education and Experience:

A combination of related education, certification, and/or relevant experience in an occupation related to the work assigned equal to three (3) years Certification related to the work assigned to the position will substitute for 2 (two) years of the required experience

History of Changes Made to Minimum Qualification

The​ ​following​ ​is​ ​a​ ​summary​ ​of​ ​changes​ ​made​ ​to​ ​this​ ​minimum​ ​qualification.

June 1, 2017 (Whole Document)

• Part of the 2017 MQ Project
• New format
• Standardized language regarding experience requirement
• Removed ‘additional higher level and/or special experience’ language. Special qualifications can appear as a Special Qualification in the job posting, if justified in the position description and job analysis.

July 22, 2017 (Whole Document)

• Added post-secondary education and certification substitution

Nov. 1, 2017 (Whole Document)

• Made grammatical changes

July 1, 2018 (G3D1TX changed to G3D1XX)

Review and correction of the classification codes to align with the 2018-19 pay plan and compensation grades approved by the CHRO

Dec. 6, 2023 (Whole Document)

• New format (updating to adhere to accessibility standards)
• Updated minimum qualifications to align with the Skills-based Hiring initiative