Medical Records Job Description

Medical Records Job Description

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Medical records provides guidance to project teams, suppliers and other disciplines to ensure compliance with company policies and procedures as well as medical device regulations.

Medical Records Duties & Responsibilities

To write an effective medical records job description, begin by listing detailed duties, responsibilities and expectations. We have included medical records job description templates that you can modify and use.

Sample responsibilities for this position include:

Prepares daily abstracting and scanning productivity statistics and presents this information to the HIM Manager on a weekly basis
Pulling records electronically and emailing them to the nurses
Review the computerized imaging indexes of documents
Ensure accuracy and conformance to accepted standards and quality for internal database system
Perform site visits to scan charts for HEDIS
Assist with scanning incoming medical records when not on site visits
Coordinates data flow, transcription, and patient information between clinical areas, admissions and finance areas
Maintain active and discharged medical records with established system
Notify staff involvement of incomplete records
Retrieve residents records, deliver as necessary

Medical Records Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Medical Records

List any licenses or certifications required by the position: RHIT, CPR, BLS, CPI, RHIA, ART, GED, BCLS, CPC, LPN

Education for Medical Records

Typically a job would require a certain level of education.

Employers hiring for the medical records job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Medical, Associates, Education, Medical Terminology, Technology, Health, Health Information Management, Health Information Administration, Health Information Technology, Computer

Skills for Medical Records

Desired skills for medical records include:

Medical records and terminology
Policies & procedures and HIPAA regulations and to complete work in compliance of these and other standards
Release of Information standards
Current state laws regarding fee structure
HIPAA regulations facility policies and procedures in regards to release of information
Manager
Safety procedures to ensuring a safe work environment and reports safety concerns to Supervisor
Medical terminology
Operations
Medical charts

Desired experience for medical records includes:

File information such as nurses notes, residents assessments, progress notes, lab reports, x-ray results, correspondence
Collect, assemble, check & file resident charts as required
Assure of adequate inventory of medical records supplies
Respond to request for medical records copies & provide material in accordance with applicable federal & state laws
Coordinates and assists with the collection, processing, filing, maintenance, storage, retrieval, and distribution of medical records according to facility policies and procedures
Collects and files in medical record all laboratory, pathology, electrocardiogram, and x-ray reports received prior to/post surgery

Medical Records Examples

1

Medical Records Job Description

Job Description Example
Our company is hiring for a medical records. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for medical records
  • Arranges all chart forms, correspondence reports (e.g., operative, lab, electrocardiogram, x-ray, pathology, ) in appropriate order per facility policy/procedure
  • Maintains and controls the release of information to authorized persons only
  • Adheres to medico-legal requirements when answering correspondence and inquiries
  • Marks and obtains all necessary signatures to complete chart, including contacting physicians’ offices regarding necessary signatures/reports within required timeframe
  • Obtains all missing chart contents needed to complete medical record
  • Adheres to established procedures for cross-referencing and indexing medical records
  • Develops and maintains an organized storage system for timely retrieval of individual medical records
  • Institutes and maintains a check-out and return system for medical records
  • Maintains confidentiality, security, and physical safety of facility medical records
  • Arranges for confidential, safe off-site storing/microfilming of medical records per facility policies/procedures, if applicable
Qualifications for medical records
  • Arranges for appropriate disposal of medical records per facility policies/procedures, if applicable
  • Services as liaison between surgery center and Transcription Company, as determined through facility processes
  • Participates in facility committees, meetings, in-services, and activities as required
  • Answers telephone and performs other miscellaneous office/clerical duties as needed
  • Proficient in Microsoft Excel, Word, and Adobe
  • Medical records experience a plus
2

Medical Records Job Description

Job Description Example
Our company is hiring for a medical records. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for medical records
  • Arranges all chart forms, correspondence reports (e.g., operative, lab, electrocardiogram, x-ray, pathology, ) in appropriate order per facility policy/procedures
  • Marks and obtains all necessary signatures to complete chart, including contacting physicians’ offices regarding necessary signatures/reports
  • Services as liaison between surgery center and transcription company, as per facility practice
  • Coordinates missing chart report for abstracting purposes for follow up to obtain records that were initially unavailable
  • Complete schedule for the Nursing Staff
  • Complete daily staffing sheets
  • Interact with employees to cover daily staffing requirements
  • Secure coverage for vacant shift, open position, vacations, as dictated by the Director of Clinical Services
  • Prepare and complete daily nursing hours report for Executive Director
  • Record employee attendance, communicates with Director of Clinical Services when issues arise
Qualifications for medical records
  • Certification through AHIMA (CCS, CCS-P, RHIT, RHIA) or AAPC (CPC, CPC-H)
  • 3+ years of acute care hospital inpatient coding required
  • LTACH experience a plus
  • Must be able to work in a virtual setting under minimal supervision
  • Must have home office set-up with high-speed Internet access
  • Minimum 1-2 years of hospital or ASC medical records experience preferred
3

Medical Records Job Description

Job Description Example
Our innovative and growing company is looking to fill the role of medical records. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for medical records
  • Schedule and assist with arranging doctor or outside appointments for residents
  • Share employee vacation requests' with Director of Clinical Services
  • Assess employees’ performance at least monthly
  • Actively participate in daily duties of dept
  • Perform quality checks to maintain the integrity of events and criteria for reporting purposes
  • Provides charts/documents requested by patients, physicians, and legal counsel following patient consent/confidentiality protocols
  • Reviews the patients’ electronic record including patient symptoms and medical history, exam results, X-ray reports, lab tests, diagnoses, and treatment plans
  • Communicates as needed with physicians and other health care professionals to clarify records request or to obtain additional information
  • Submits files/documentation to physicians and other clinicians as requested for review, quality assurance checks, and other purposes
  • Uses computer programs if requested to tabulate and analyze data to improve patient care, control costs
Qualifications for medical records
  • Computer knowledge/literacy
  • Must be able to adhere to ASC financial and admitting policies
  • Knowledge of insurance verification and collection processes strongly preferred
  • Minimum 1-2 years of hospital/ASC or medical records experience preferred
  • Must have a H.S
  • RHIA, RHIT, CCS, CCA (or eligible) and/or working knowledge of CPT-4 and ICD-10-CM coding systems
4

Medical Records Job Description

Job Description Example
Our company is growing rapidly and is looking for a medical records. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for medical records
  • Dealing with insurance companies
  • Organzing and filing important documents
  • Provides clerical support which may include faxing, sorting orders and Plans of Care, copying, filing, and /or copying
  • Tracks and coordinates with appropriate internal personnel for missing documentation for patient charts
  • Answer, forward, and log incoming medical record requests
  • Comply with state and federal privacy laws and state statutes in regards to billing and invoicing medical records
  • Resolve patient and requester inquiries, both verbal and written
  • Document all communication relative to patient accounts
  • Work with team and appropriate staff to successfully resolve record requests
  • Communicate changes in reimbursement rates, state laws/requirements, or vital account billing information
Qualifications for medical records
  • Working knowledge of computers, internet access, and the ability to navigate within an automated systems variety of software packages such as Outlook, Excel and Word
  • 1-2 years recent coding experience in an acute care hospital or successful completion of the coding curriculum in an approved RHIA/RHIT program.Answer telephones
  • Two years professional work experience working in a customer service environment in the last five years
  • Minimum 1-2 years of medical records experience preferred
  • Knowledge of The Joint Commission Standards preferred
  • Must be able to adhere to financial and admitting policies
5

Medical Records Job Description

Job Description Example
Our company is growing rapidly and is hiring for a medical records. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for medical records
  • Maintains master patient index by completing assigned portion of daily audit trail
  • Initiates the medical record by creating and processing the patient care record folder
  • Maintains record availability by processing charts into the department
  • Delivers charts to assigned areas of the surgery center by following established routing procedures
  • Maintains quality results by following company standards
  • Serves and protects the organization and patients by adhering to professional standards, hospital policies and procedures, federal, state, and local requirements, and ASC standards
  • Enhances medical records and hospital reputation by accepting ownership for accomplishing new and different requests
  • Corresponds with outside medical facilities and contract vendors to request pertinent medical information to place in the medical record using appropriate and authorized ICE and IHSC forms
  • Reviews all documentation for completeness and routes incomplete documents to the appropriate provider for correction prior to placing/scanning in the medical records
  • Retrieves and transports required and requested medical records to the appropriate provider throughout the medical facility using appropriate IHSC policy and procedures to maintain privacy
Qualifications for medical records
  • Some knowledge and experience with computers, and insurance and coding is preferred but not required
  • Five years progressive supervisory experience in an HIM Department or healthcare business environment
  • Supervisory experience in a union environment preferred
  • Ability to read and understand oral and written instructions, and effectively communicate information
  • Registered Health Information Technician (RHIT) certification, preferred, as required by the service line
  • Working knowledge of ICD-10-DM coding system, preferred

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