Medical Records Specialist Job Description
Medical Records Specialist Duties & Responsibilities
To write an effective medical records specialist job description, begin by listing detailed duties, responsibilities and expectations. We have included medical records specialist job description templates that you can modify and use.
Sample responsibilities for this position include:
Medical Records Specialist Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Medical Records Specialist
List any licenses or certifications required by the position: BLS, RHIT, CCS, CAHIIM, CPC, CTR, ART, RHIA, RRA, CPR
Education for Medical Records Specialist
Typically a job would require a certain level of education.
Employers hiring for the medical records specialist job most commonly would prefer for their future employee to have a relevant degree such as Associate and Collage Degree in Education, Medical, Health, Department of Education, Technical, Graduate, Business, Office Management, Medical Terminology, Health Information Management
Skills for Medical Records Specialist
Desired skills for medical records specialist include:
Desired experience for medical records specialist includes:
Medical Records Specialist Examples
Medical Records Specialist Job Description
- Retrieves and sorts medical records into proper chart order, ensuring that records are updated
- Reviews and audits medical records for chart reviews
- Processes requests for health information
- Handles phone calls to explain compliancy policy and requirements of immunization policies
- Reviews submitted immunization records
- Assists in orientation sessions to collect immunizations and clear MMR holds
- Work in an office setting and use office equipment
- Candidate will be required to send documents to Anthem via a correspondence delivery system to be determined by the department
- Responsible for performing Clinical Documentation Improvement (CDI) chart reviews (concurrent, pre-bill and retrospective) for improving overall quality and completeness of clinical documentation for inpatient accounts
- Facilitate modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and health records coding staff to improve quality, accuracy, and completeness of clinical documentation in real-time
- Knowledge of HIPAA rules and regulations preferred
- Analyze content of medical records to ensure compliance with TRICARE contractual requirements for timeliness and documentation
- Request medical records, enter information into database, and send follow-up letter to facility if records not received
- Prepare, scan, and perform review of scanned medical records to ensure that a quality reproduction has been made
- Distribute the medical records appropriately through the Department according to government contract requirement or appropriate requestee including in the TriCare Quality Monitoring Committee (TQMC)
- Complete payment voucher and send to finance for processing
Medical Records Specialist Job Description
- Monitors the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcome data
- Communicates with members of the patient care team on clinical documentation improvement strategies and workflows, including a real-time physician escalation process and real-time concurrent notifications (utilization review, quality and risk management)
- The candidate in this position will be instrumental with enhancing the overall quality completeness and accuracy of hospital health record documentation
- Track all communications
- Process requests for private health information (PHI), narrative reports, depositions, telephone or in-person conferences from patients, attorneys, insurance companies, Creates, tracks and collects pre-payment billings for such reports/records
- Organize patient files when necessary
- Date stamps incoming documents to facilitate processing
- Proper invoicing for medical records
- Verify immunizations and enter the data
- Attend student orientation/registrations to input immunization data
- Ability to work between during the hours of 6 am
- Must have experience with EMR or EHR
- Experience with providing visible participation and support of major change initiatives preferred
- Receive and review incoming medical records - must understand the difference in a progress note and physician's note on a medical record
- Follow-up on incomplete requests from facilities - should have exceptional phone and email etiquette
- Experience working with EMR systems (Epic, Allscripts)
Medical Records Specialist Job Description
- Provides excellent customer service by being attentive, respectful and professional at all times
- Maintains a neat, clean, and professional appearance and observes the dress code established by the company
- Maintains a clean and orderly work area, ensure that records are properly stored before leaving area
- Works within scope of position and direction, willingly accepts assignments and is available to take on additional duties and assist where needed
- Maintains confidentiality, information security and ethical behavior when handling all medical records
- Attends and participates in required education training sessions and staff meeting as scheduled and assigned
- Promptly reports any customer service concerns to supervisor and or any potential HIPAA violations whether actual or perceived
- Informs supervisor of work difficulties, special project request from unit, and fluctuation volume in daily workload
- Checks the company’s email and communication systems, such as public folder and EPM, to processes emails on a daily basis
- May coordinate efforts for compliance to subpoena requests from the General Counsel regarding medical records
- Leads quality improvement activities, meetings and discussions with and between other departments within the Health Plan
- Must have previous medical records experience
- Must be dependable, organized, confidential and able to work in a fast-paced corporate environment
- Must demonstrate proficiency with general office software (Microsoft Word, Excel and PowerPoint)
- Must have a desire to work in the healthcare field
- Preferred certifications include Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS)
Medical Records Specialist Job Description
- The Hospice Medical Records Specialist participates in the Hospice's QA/PI program, including auditing medical records, collecting data, and preparing reports as directed
- He/she addresses all outside requests for medical records or related information
- The Hospice Medical Records Specialist also assists with new employee orientation and continuing employee education
- Documentation is compliant with Hospice regulations
- Reporting discrepancies
- Release of records compliance
- Hospice requirements for documentation
- Enters all prescription and order information in current software system
- Documents procedures and processes for entry of orders in the software system
- Sets up electronic patient medical record file and scans in all medical record documentation received with order
- Minimum of one (1) year ICD-9-CM coding and abstracting experience in a health care environment or medical records department
- Knowledge of typewriter/word processor, personal computer and other routine office equipment
- Ability to maintain a 95% coding accuracy rate and to process a minimum of 25 charts per day
- Effective oral and written communication skills are required to work with medical, nursing, and other allied health staff external medical facilities requesting medical record information
- Develops/assists with account management and ongoing training of various office users
- Evaluate clients' workflows, documents and procedures for implementation and customized follow-up training
Medical Records Specialist Job Description
- Manages all incoming faxes by copying to appropriate electronic patient medical record or forwarding to appropriate employee
- Manages all medical record documentation received by mail or other sources and scans into appropriate electronic patient medical record
- Communicates receipt of documentation and assigns task in current software system to appropriate employee for next step in process
- Consistently organizes and maintains electronic patient medical records with established format and process
- Enters new prescribers, Health Care team members and facility information into current software system using established protocol
- Periodically reviews prescriber and facility information and inactivates any duplicated information in appropriate standard protocol
- Performs EMR audits to ensure accuracy
- Provides necessary follow-up throughout the process
- Seeks and suggests improvements
- Cross-Trains to help other customer care team members
- Assist with special "out-of-the-box" technologically innovative and clinically forward projects
- Conduct off-site visits to client offices mainly located in Nassau, Suffolk and Queens
- Some night and weekend remote support may be required
- Associates degree minimum requirement
- Must have minimum of 1 year of work experience in EMR/EHR implementation in a healthcare setting
- Experience with Microsoft Word/Excel required