Purpose: The medical records specialist is responsible for managing the medical records of the facility, including preparing, storing, and retrieving patient health records. The medical record Specialist reviews medical records for compliance with approved policies. Works independently and as part of a quality management department. Qualifications: Records Management Specialist is responsible for medical records and the individual
-Is 18 years of age or older with the ability to read, write and understand how to follow instructions AND
-Has no violent criminal record or substantiated findings of abuse or neglect listed on the North Carolina
Health Care Personnel Registry High School Diploma or equivalent
-Previous medical office experience is preferred.
-Minimum of one year experience in a medical office setting
-Have high school diploma, bachelor degree preferred
-Be able to manage projects; conduct research; and disseminate information by using the telephone, mail services, Web sites, and email.
-Operate a variety of office equipment, including fax machines, photocopiers, scanners,videoconferencing and multi line telephone systems.
-Create spreadsheets, compose correspondence, manage databases, and develop presentations, writereports, using desktop publishing Microsoft office software and digital graphics.
-Negotiate with vendors, purchase supplies, manage areas such as stockrooms or corporate libraries,and retrieve data from various sources.
Major Responsibilities 1.Prepares new patient charts, gathering documents and information from paper sources and/or electronic health record.
2.Ensures medical records are assembled in standard order and are accurate and complete.
3.Creates digital images of paperwork to be stored in the electronic medical record.
4.Files paperwork and reports in patient charts, ensuring they are completed in an accurate and timely manner (within 7 days of submission).
5.Ensures files are stored in the designated area according to storage procedures.
6.Responsible for safeguarding patient records and ensuring compliance with HIPAA standards.
7.Responds to requests for patient records, both within the facility and by external sources,retrieving them and transmitting them appropriately.
8.Retrieves medical records from offsite chart storage facilities when needed.
9.Performs other clerical tasks as needed, such as answering phones, faxing, and patient check in and out
10.Maintains the compliance tracking database, and assist by managing records and ensuing charts are in compliance with state, federal and service regulations.
11.Maintain updated consumer database by entering all new consumers and each consumer referral as it is received.
12.Understand the various requirements for documenting, requesting authorization, and invoicing all community based services. Compile all documentation according to specific billing guidelines established and submit to the designee as required.
13.Provide administrative support to all Program Personnel, including, but not limited to: using a computer, typing reports, scheduling and attending meetings, recording and distributing meeting minutes relative to job responsibilities, completing required documentation.
14.Provide evaluation support including, but not limited to: consumer mail-outs, compilation and recording of consumer data, proof reading.
15.Maintain patient database enrolled /previously enrolled. Maintains a system for accurate assembly, disassembly, and filing, of patient records
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