Description

Medical Records Specialist

Department

Medical Records

Created

9/3/2019

Reports to

Medical Records Manager

Revised

9/20/2024

FLSA Status

Non-exempt

EEO - 1

Administrative Support Workers

Position Type

Full Time

Travel

Occasional travel within service area is required.

Work Hours

Monday – Friday, 8:00 am – 5:00 pm

Positions Supervised

None

Summary

The Medical Records Specialist position provides quality customer service to clients, staff, and community partners by assisting with the sharing of treatment and business information, by overseeing the clinical record as a current source of a client’s treatment encounters, responding to external requests for treatment information, and obtaining information from other facilities as requested.

Essential Functions

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

• Assists individuals with questions or requests in a professional and courteous manner.
• Accurately uploads incoming and existing paperwork into the client electronic medical record.
• Manages the retention and destruction of inactive client charts by monitoring the length of inactivity, destroying charts that have been inactive for more than 10 years, and recording identifying information for each chart that will be destroyed.
• Generates weekly reports to ensure the initial intake assessment is completed by intake therapist and all initial documents are in the EMR.
• Fulfills tasks assigned regarding releases of information from the client’s electronic medical record.
• Administers requests for information from clients, external health care providers, and other entities in compliance with agency policies and relevant laws by receiving and auditing the release form, asking the primary provider to complete a summarized progress report, logging the release data, making copies of documents, and submitting the information to the requestor.
• Assists in the discharge process of inactive clients by reviewing the report of medical records eligible for discharge, preparing the paperwork for the primary provider to examine and write discharge summary, monitoring that services have not been scheduled with the client, and closing all assignments and programs in the electronic medical record.
• Prepares clinical records for audits by ensuring the necessary documents are in orderand submitting within the required timeframe.
• Manages incoming faxes.
• Generates weekly letters for clients that have not been engaged in services notifying them that their chart will be/has been closed.

Work Environment

This job operates in a professional office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, and credit card machines.

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. This list is not exhaustive and may be supplemented as necessary.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; handle objects; grasp and reach for items with hands and arms; manipulate hands and fingers; climb stairs; balance; stoop, kneel, or crouch; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Language skills are required, including the ability to read, write, comprehend, and speak the English language. This position also requires the ability to interpret written materials, write reports and business correspondence, and effectively present and respond to questions. 

Important Information

This job description has been examined for compliance with the Americans with Disabilities Act (ADA) and the Fair Labor Standards Act (FLSA). The agency has reviewed this job description to ensure that essential functions and basic duties have been included. It is intended to provide guidelines for job expectations and the employee’s ability to perform the position described. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate. This document does not represent a contract of employment, and the agency reserves the right to change this job description and/or assign tasks for the employee to perform, as the agency may deem appropriate.

Requirements

Skills & Abilities

Education

High school diploma or equivalent. Associate’s Degree is preferred.

Experience

N/A

Certifications & Licenses

N/A

Computer Skills

Computer experience in Microsoft Office programs and basic computer fluency.

Additional Qualifications

Possess excellent customer service skills; ability to handle and respect confidential, sensitive information; demonstrated ability to work with large volumes of information and possess competency in conducting highly organized and detail-oriented work.