Job Description

Under the limited supervision of the program's Regional Supervisor, performs highly complex, technical, and consultative work in conducting active surveillance of birth defects. Identifies cases of birth defects through case finding and medical record review and abstracts complex medical information on those cases from medical records at assigned health care facilities following state law and program procedures. Analyzes information from multiple procedure results and diagnoses and develops a complete yet concise description of each birth defect. Codes each birth defect using the program's detailed birth defects coding system. Enters and edits data in multiple computer databases. Reviews and analyzes own work to identify and eliminate errors and inconsistencies. Performs work in a professional, responsible, and timely manner, ensuring the collection of data in a confidential, accurate, consistent, and reliable manner. Requires individual planning, organization, initiative, and flexibility in carrying out duties. Serves as a liaison between the program and the staff at assigned health care facilities. Serves on program and regional teams to improve processes and procedures. Assists with special epidemiological studies on birth defects. Work is performed with considerable latitude for the use of initiative and independent judgment.

Essential Job Functions

(40%) Attend work on a regular and predictable schedule in accordance with agency leave policy and performs other duties as assigned. Coordinates and conducts abstraction activities at health care facilities, either in person or remotely. For potential cases meeting the program’s case definition, accurately abstracts complex medical information from electronic and/or paper medical records following instructions and program procedures, and using knowledge of medical terminology, anatomy, and diagnostic procedures. Analyzes all procedure results and other diagnostic information to develop a complete "picture" of the child's condition. Combines information from multiple procedures and diagnoses to develop a complete yet concise description of each birth defect. Codes each birth defect using the program’s detailed birth defects coding system containing over 1,000 distinct codes. Conducts detailed quality checks on each abstraction for accuracy and completeness. Enters information for each abstraction into a computerized abstraction database. Combines duplicate abstraction records as required per program procedures. Submits electronic abstraction records to the Quality Assurance Specialist for further quality assurance review and processing. Enters and/or updates information in the case finding database. Assists coworkers with abstraction activities at other facilities as requested/required.

(25%) Coordinates and conducts medical record review activities at health care facilities, either in person or remotely. Requests and reviews medical records of potential cases identified during case finding activities, as well as potential cases from other facilities, from other regions, and from Central Office staff. Using knowledge of medical terminology, anatomy, and diagnostic procedures, identifies records for abstraction by determining which potential cases meet the program’s case definition. Follows program procedures when reviewing medical records. Conducts quality checks on own medical record review activities for accuracy and completeness. Enters and/or updates information in the case finding database. Assists coworkers with medical record review activities at other facilities as requested/required.

(15%) Coordinates and conducts case finding activities at health care facilities. Requests and reviews facility discharge ICD (International Classification of Disease) line lists, facility unit logs, and other data sources. Assesses the quality of data received from the facilities. Using knowledge of medical terminology, anatomy, and diagnostic procedures, identifies potential cases by comparing information found in these sources to the program's list of conditions warranting a chart review. Follows program procedures when conducting case finding activities. Conducts quality checks on own case finding activities for accuracy and completeness. Enters and/or updates information in the case finding database. Assists coworkers with case finding activities at other facilities as requested/required.

(10%) Creates, checks for accuracy, and submits required and requested reports in a timely manner following Department of State Health Services (DSHS) and program policy/procedures. Uses a laptop and/or desktop computer and various software (including Word, Access, Excel, and Outlook) to create, edit, and submit documents and reports including employee time and leave, travel, monthly workload activities, facility data, results of special investigations, recent training summaries, and letters. Tests new and/or updated versions of program’s data collection and processing software and provides feedback on changes and/or improvements.

(5%) Establishes and maintains effective working relationships with staff at assigned health care facilities. Meets regularly with appropriate facility staff (including Information Technology (IT), medical records, clinical, security, laboratory, and others) to enhance communication and encourage cooperation with reporting provisions of the birth defects law. Identifies potential new data sources within facilities. Serves as a liaison between Health and Human Services Commission (HHSC) IT staff and hospital IT staff to assist in solving complex issues with remote access of medical records. Creates and updates facility reference sheets and/or databases. Promotes and maintains effective working relationships with other program staff, as well as staff from other DSHS programs and outside entities. Educates health care workers on birth defects and program activities through presentations and displays.

(5%) Performs other duties as assigned. Other duties as assigned include but are not limited to actively participating and/or serving in a supporting role to meet the agency’s obligations for disaster response and/or recovery or Continuity of Operations (COOP) activation. Such participation may require an alternate shift pattern assignment and/or location. Assists with special epidemiological studies. Participates in program and regional teams as invited/directed to improve processes, procedures, and practices or to meet regional goals. Trains coworkers on program procedures.

Knowledge Skills Abilities

Knowledge of medical terminology, human anatomy, human physiology, obstetrics, and neonatology; of ICD-9, ICD-10, or other disease/medical procedure coding systems; of medical procedures, especially those relating to pregnancy, labor/delivery, neonates, and infants; of the medical records setting and procedures; of data collection & retrieval methods, database management, and quality assurance/control principles and procedures; and of the principles and practices of public health.

Skill in medical coding; in training; in quality assurance; in asking questions when needed and identifying resources to obtain needed information; in perceiving and reacting sensitively to the needs of others; in motivating individuals to complete tasks; and in conflict resolution, mediation, facilitation, and sound decision making.

Ability to follow program procedures and protocols; to read, analyze, and interpret complex medical information from medical records; to accurately and completely collect (abstract) data from medical records including diagnoses, procedures, and histories; to handwrite legibly and spell accurately; to establish and maintain cooperation from health care facilities to ensure complete case-finding, record review, and abstraction; to produce accurate and complete work through review, identification, and correction of errors; and to produce accurate and appropriate reports.

Ability to prioritize work, manage time effectively, and organize schedules optimally to balance field and office work; to assemble information, materials, etc. into logical order; to anticipate future consequences of present alternatives; to manage multiple concurrent tasks/assignments, to handle a large workload, and to meet deadlines; to identify, recall, and attend to essential details; to understand and follow written and oral instructions; and to learn new information and tasks quickly and proficiently.

Ability to adapt to change and modify behavior in response to frequent changes in situations or priorities; to approach problems in a logical and pro-active manner; to identify current and potential problems, analyze all relevant concerns and identify possible solutions in reaching logical conclusions; to pay attention to important details; to be a self-starter and work independently; and to provide imaginative solutions to work problems.

Ability to act in a sound, logical, appropriate manner based on well thought out professional analysis of a situation or problem; to reach logical conclusions based on evidence/facts and make decisions; to handle stressful situations, to exercise tact and diplomacy, and maintain a professional demeanor; to handle constructive criticism; to apply principles of Total Quality Management and Continuous Quality Improvement and to implement those initiatives; and to set a good example of professional behavior.

Ability to read and interpret laws, policies and procedures governing birth defect surveillance. Ability to be attentive and to collect essential information; to communicate effectively, clearly, accurately, and concisely with all customers and diverse groups, in writing and orally; to work effectively as part of a team member, work in a cooperative and productive manner and actively participate in team meetings; to maintain effective working relationships with customers (public, medical community, DSHS staff, etc.); to handle difficult situations; to negotiate and/or mediate; and to present complex information to a variety of audiences.

Ability to work with computers (enter/edit data in word processing, database, spreadsheet, and electronic mail software); to move, transport, and utilize computers, books, and peripheral devices weighing up to 30 pounds; to read, understand, explain, implement and comply with laws, polices, and procedures governing birth defects surveillance; to follow all DSHS policies & procedures including Guiding Principles, Code of Ethics/Standards of Conduct, and Universal Expectations of Personal Responsibility; to follow strict confidential provisions of the birth defects and public health laws and program security procedures; to provide transportation and travel daily within the region; to travel on short notice; and to travel to Austin or other parts of Texas.

Registration Or Licensure Requirements

None

Initial Selection Criteria

Requires experience in the use of medical terminology, and Human Anatomy & Physiology.
Experience in the use of the ICD coding system, BPA or other state-wide registry coding schemes is preferred.
Experience in reviewing data and reports found in electronic or paper medical records is preferred.
Experience abstracting data found in electronic, or paper medical records is preferred.
Requires experience in the use of different computer systems, spreadsheet, and database software.

Additional Information

Information on the application must clearly state how applicant meets the initial selection criteria in the summary of experience section of the application. All fields on the application must be filled-in completely. Resumes will not be accepted in lieu of an application but may be provided as supplemental materials.

Regular local travel is required to conduct surveillance activities in regional health facilities. Employee must provide reliable transportation. Out-of-town and/or overnight travel is occasionally required to conduct surveillance activities, to assist other regions, and to attend program meetings and/or trainings. Non-standard work hours may be required on occasion.

Must adhere to confidentiality provision of birth defects laws and agency policies.

The salary for this position is $3,793.41, which follows HHS starting salary guidelines.

This position’s ability to telework will be determined by agency and division telework policies and may be required to come into the office, as directed, to fulfill essential job functions.

MOS Code

4076- 68S, MH,870, 4E0X1 Note: Military occupation(s) that relate to the initial selection criteria and registration or licensure requirements for this position may include, but not limited to: 68S, HM, 870, 4E0X1. All active duty military, reservists, guardsmen, and veterans are encouraged to apply if qualified to fill this position. For more information see the Texas State Auditor’s Military Crosswalk at http://www.hr.sao.state.tx.us/Compensation/JobDescriptions.aspx.

HHS agencies use E-Verify. You must bring your I-9 documentation with you on your first day of work.

I-9 Form - Click here to download the I-9 form.

In compliance with the Americans with Disabilities Act (ADA), HHS agencies will provide reasonable accommodation during the hiring and selection process for qualified individuals with a disability. If you need assistance completing the on-line application, contact the HHS Employee Service Center at 1-888-894-4747. If you are contacted for an interview and need accommodation to participate in the interview process, please notify the person scheduling the interview.

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