Job Summary/Objective:

The Medical Records Specialist is responsible for managing the medical records of the facility, including preparing, storing, and retrieving patient health records. The Medical Records Specialist reviews medical records for compliance with approved policies, is responsible for their completeness, proper release and maintenance. Works independently or as part of a medical records department..

Essential Job Functions

• Medical Records Specialists organize and maintain health information both in paper files and in electronic systems. They check data for accuracy, assign codes for insurance reimbursement, record information and keep file folders and electronic databases up to date.

• Prepares new patient charts, gathering documents and information from paper sources and/or electronic health record.
• Ensures medical records are assembled in standard order and are accurate and complete.
• Creates digital images of paperwork to be stored in the electronic medical record.
• Files lab reports, correspondence, physician dictation/notes, progress notes, radiology reports and other approved document, in charts, ensuring they are completed in an accurate and timely manner.
• Ensures that charts for follow-up patients, who are to have testing performed prior to their next visit, are up-to-date with the reports of the test results, and that x-rays are also available.

• In addition to their clerical duties, Medical Records Specialists often consult with health care professionals to make sure information is accurate. They must also follow best practices for security and patient confidentiality.

• Ensures files are stored in the designated area according to storage procedures.
• Responsible for safeguarding patient records and ensuring compliance with HIPAA standards.
• Ensures fulfillment of all mailed-in and faxed requests for medical records from insurance companies, managed care plans, hospitals, attorneys, patients and other physicians-when appropriate releases are provided
• Answers phone inquiries regarding medical records and performs other clerical functions within the team as designated by supervisor.

Required Education and Experience

• High School graduate or equivalent
• Two years of related experience

Preferred Education and Experience

• Knowledge of medical terminology

AAP/EEO Statement
In order to provide equal employment and advancement opportunities to all individuals, employment decisions at SFENTA will be based on qualifications and job-related abilities. SFENTA does not discriminate in employment opportunities or practices on the basis of race, color, religion, sex, national origin, age, disability, ancestry, sexual orientation, marital status, gender identity or any other characteristic protected by law. SFENTA will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in undue hardship.