Medical Records Specialist

Description

JOB SUMMARY:

The Medical Records Specialist maintains records of patient care by compiling, reviewing and completing documentation of patient conditions, treatment plans and health outcomes.

QUALIFICATIONS:

High school graduate or equivalent, and prior medical records/HIM or clinical experience

DUTIES AND RESPONSIBILITIES:

1. Maintains medical records operations by following policies and procedures, and reports needed changes.

2. Initiates medical record by searching master patient index; identifies existing patient records or need to assign a new number; interacts with registration areas and physicians' offices for information verification; processes or creates the record folder.

3. Ensures medical record availability by routing records to admissions and emergency departments, physicians, and other authorized hospital staff; maintains chart location systems.

4. Completes medical record by reviewing information; notifies health care providers of record deficiencies; tracks outstanding records.

5. Resolves medical record discrepancies by collecting and analyzing information.

6. Maintains historical reference by abstracting and coding clinical data, such as diseases, operations, procedures, and therapies, using standard classification systems; files documents.

7. Provides medical record information by answering questions and requests of patients, hospital staff, law firms, insurance companies, and government agencies.

8. Maintains patient confidence and protects operations by keeping information confidential; follows release-of-information protocols.

9. Conserves resources by using equipment and supplies as needed to accomplish job results.

10. Contributes to team effort by accomplishing related results as needed.

11. Adheres to all Round Rock Surgery Center and departmental policies and procedures.

12. Displays regular and predictable attendance.

13. Completes other job duties as assigned.

Requirements

KNOWLEDGE AND SKILLS:

· Time management and organization skills

· Attention to detail and accuracy

· Quality focus, professionalism, and ability to prioritize

· Documentation and data entry skills

· Excellent written and oral communication skills

· Superior customer service skills

· Knowledge of medical terminology

· Familiarity with HIPAA compliance

· Ability to type 50+ wpm

· Ability to upload information from CDs

· Knowledgeable with Outlook, EMR systems and computer savvy a plus

WORKING CONDITIONS:

Environmental Conditions: Medical Office environment, Ambulatory Surgery Center

Physical Conditions:

· Must be able to work as scheduled, typically Monday thru Friday 8:00-5:00

· Must be able to sit and/or stand for prolonged periods of time

· Must be able to bend, stoop and stretch

· Must be able to lift and move boxes and other items weighing up to 25 pounds.

· Requires eye-hand coordination and manual dexterity sufficient to operate office equipment, etc.