Job Description: Medical Records Specialist

Medical Records Specialist

Job Summary
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
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.

Essential Duties and Responsibilities

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.

Education and/or Work Experience Requirements
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.

Education and/or Work Experience Requirements

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.

Physical Requirements
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

Interested? Send your resume today!