Job Description

Job Summary

The medical records specialist is responsible for reviewing and processing document retention requests and inquiries. This includes organizing and maintaining Medical Records and document retention processes and workflows. The Specialist also participates in quality assurance activities such as chart audits and data and document collection activities.

Essential Responsibilities and Metrics

• Prepares, reviews, and processes document retention inquiries and medical records requests under the direction of the Clinical Quality and Records Manager and/or Director of Clinical Quality and Compliance, following applicable federal and state confidentiality laws and regulations
• Prepares, reviews, and develops maintenance processes and workflows for open and closed medical records, including storage and updates under the direction of the Clinical Quality and Records Manager and/or Director of Clinical Quality and Compliance following applicable federal and state confidentiality laws and regulations 
• Assists the Clinical Quality and Records Manager and/or Director of Clinical Quality and Compliance with internal chart monitoring and auditing activities, including data and document collection 
• Assists the Clinical Quality and Records Manager in updating, revising, and implementing document retention and medical record policies, procedures, and workflows.
• Assists the Clinical Quality and Records Manager in providing training to all:
  • Clinical staff regarding any required changes that may impact medical records 
  • Applicable staff regarding document retention and medical record requests, including completion of request forms, following federal regulations and state confidentiality laws 

• Supports activities related to accreditation and third-party audits, including preparation, submission, reporting, and corrective action follow-up
• Participates cooperatively and works effectively in performance improvement activities, committee work, mandatory in-services, and strategic planning 
• Applies knowledge of health care principles and standards of confidentiality, client rights, safety, incident and sentinel event reporting, and personnel policies to all assigned responsibilities 

Qualifications

• High School diploma 
• 3-5 years of experience working in a medical records department 
• Demonstrate the ability to learn applicable federal and state confidentiality and privacy laws. 
• Proficient in Microsoft, Word, Excel

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