Medical Records Specialist
Job Summary |
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The Medical Records Specialist is responsible for organizing, maintaining, and safeguarding patient health records. They play a crucial role in ensuring the accuracy, confidentiality, and accessibility of medical records to support patient care, billing, and compliance with healthcare regulations. |
Essential Duties and Responsibilities |
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- Create and maintain patient records, including electronic health records (EHR) and paper files.
- Ensure the accurate and complete documentation of patient information, including medical history, diagnoses, treatments, and test results.
- Accurately input and update patient information into electronic databases.
- Ensure proper coding and indexing of medical records for easy retrieval.
- Regularly review, update, and verify the accuracy of patient records.
- Ensure compliance with medical record retention policies and disposal procedures.
- Strictly adhere to the Health Insurance Portability and Accountability Act (HIPAA) regulations to maintain patient confidentiality.
- Implement security measures to safeguard electronic and paper records.
- Retrieve patient records as needed for healthcare providers, staff, and authorized personnel.
- Ensure that records are accessible in a timely manner to support patient care and other healthcare functions.
- Process requests for medical records from patients, legal representatives, insurance companies, and other authorized parties.
- Verify the authenticity and authorization of record requests.
- Participate in periodic audits to assess the accuracy and completeness of medical records.
- Assist in addressing any discrepancies or deficiencies in documentation.
- Organize and file medical documents, reports, and correspondence in a systematic manner.
- Maintain the integrity of record filing systems.
- Proficiency in using EHR systems to manage and retrieve patient records.
- Ensure the security and integrity of electronic records.
- Generate reports on medical record activities, including tracking record volume and turnaround times.
- Provide regular updates to management on record management trends and issues.
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Education and/or Work Experience Requirements |
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- High school diploma or equivalent; post-secondary education or training in health information management is preferred.
- Certification as a Certified Health Data Analyst (CHDA), Registered Health Information Technician (RHIT), or Certified Professional in Health Informatics (CPHI) is a plus.
- Strong knowledge of medical terminology, healthcare procedures, and legal requirements related to medical records.
- Familiarity with electronic health record (EHR) systems and health information management software.
- Excellent organizational and attention-to-detail skills.
- Strong communication and interpersonal skills.
- Ability to maintain confidentiality and handle sensitive information responsibly.
- Knowledge of HIPAA regulations and healthcare compliance.
- Proficiency in data entry and record management.
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Physical Requirements |
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- Sit or stand for extended periods of time.
- Must be able to lift and carry, push or pull up to 50 lbs
- Must be able to talk, listen and speak clearly in person and on the telephone
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