Medical Records Specialist

Job Description

Job DescriptionDescription:

The Medical Records Specialist will be responsible for maintaining accurate and confidential medical records for our residents, ensuring compliance with regulatory standards and facilitating the efficient flow of information within the facility. This position requires strong organizational skills, attention to detail, and a commitment to maintaining the integrity and confidentiality of medical records.

Primary Responsibilities and Duties:

• Collect, organize, and maintain medical records for all residents, ensuring completeness, accuracy, and compliance with regulatory requirements.
• Review incoming documentation, including physician orders, progress notes, lab results, and diagnostic reports, and file records in accordance with established procedures.
• Create new medical records for newly admitted residents, inputting demographic information, insurance details, and other relevant data into electronic health record systems.
• Retrieve medical records as requested by authorized healthcare providers, staff members, regulatory agencies, and legal representatives, ensuring timely and accurate record retrieval.
• Prepare medical records for external audits, surveys, and reviews by regulatory agencies, ensuring compliance with documentation standards and facilitating the resolution of any deficiencies.
• Maintain the confidentiality and security of medical records, adhering to HIPAA regulations and facility polices governing access, disclosure, and release of protected health information.
• Assist with the scanning, indexing, and electronic filing of paper documents into electronic health record systems, ensuring accuracy and completeness of electronic records.
• Perform regular audits and quality checks of medical records to identify discrepancies, errors, or missing documentation, and take corrective action as needed.
• Provide support and assistance to healthcare providers, nursing staff and administrative personnel regarding medical record documentation, retrieval, and interpretation.
• Assist with the coordination of medical record transfers for residents who transfer to other healthcare facilities or agencies, ensuring continuity of care and accurate record transmission.
• Collaborate with team embers including nurses, physicians, therapists, and social workers to facilitate communication and information sharing related to resident care.
• Perform all other duties assigned.

Schedule: Monday-Friday, Weekends Off

Requirements:

• Minimum of 1 year of experience working in medical records management or health information management, preferably in a skilled nursing facility or long-term care setting.
• Strong knowledge of medical terminology, healthcare documentation practices, and regulatory requirements governing medical records management.
• Proficiency in electronic health record systems and basic computer skills, including Microsoft Office and database management.
• Excellent organizational skills and attention to detail, with the ability to manage multiple tasks, prioritize responsibility, and meet deadlines in a fast-paced environment.
• Effective communication and interpersonal skills, with the ability to interact professionally with residents, families, staff members and external parties.
• Understating of confidentiality requirements and HIPAA regulations governing the privacy and security of protected health information.
• Ability to maintain confidentiality and exercise discretion in handling sensitive information and medical records.
• Ability to build rapport with residents through a compassionate and caring demeanor.

Physical Requirements:

• Work performed in a medical setting due to the need to work in person with residents, families, and staff.
• Ability to sit, stand and move around the facility for extended periods.
• Manual dexterity and hand-eye coordination for using computers, keyboards, and other office equipment.
• Visual acuity and auditory ability to review and interpret medical records, electronic documents, and written communications.
• Ability to lift and carry boxes of medical records and supplies, as needed, up to 5lbs.
• Ability to bend, stoop, kneel, and reach to access files, storage cabinets, and other work-related materials.
• Ability to work in an office environment with moderate noise levels and occasional interruptions.
• Maintain regular attendance and timeliness as set forth within the work schedule designated by the department supervisor/manager.