Medical Records Specialist

Maintains medical records in accordance with federal and state guidelines and established policies and procedures to ensure a complete medical records program. Ensures quality, accuracy, accessibility, and security across paper and electronic systems. Directs, analyzes, researches, and reviews critical data points to determine missing components of the comprehensive medical record. Provides guidance, support, communication, and coordination of documents with legal, operations, and clinical programs. Reviews quality data to ensure accuracy and support quality improvement efforts.

• Gathers, prints, and collects responsive pieces of requested medical records for production to residents, authorized representatives, or attorneys.
• Works with Clinical Risk Manager to help identify potential compensable events.
• Coordinates with campuses to ensure incident workflows and soft files are completed when certain events occur.
• Uses classification systems to code and categorize patient information for risk and legal reviews.
• Assists in developing procedures to ensure records are properly stored and copied for production requests.
• Works with Compliance to ensure proper authority to produce requested records.
• Protects the security and confidentiality of medical records.
• Reviews records for completeness, accuracy, and regulatory compliance.
• Assists with training on record documentation and retention.
• Collaborates with Paralegal staff to obtain documentation for litigation or claim purposes.
• Identifies and requests soft file documentation on events.
• Serves as a liaison with Clinical Documentation Specialist to identify documentation opportunities.
• Supports legal/risk system practices and effective system use for quality improvement.
• Provides knowledge of care provider systems to create solutions that improve quality across the care continuum.
• Assists with policies and procedures to ensure accurate documentation in MatrixCare.
• Uses trends and quality data to identify issues with retention and production of medical records.
• Provides education related to maintaining comprehensive medical records.
• Directs automated reporting to deliver timely information for real-time decision-making.
• Uses critical thinking to identify and communicate missing documentation needed for a complete record.
• Collaborates with department heads, divisional support, and campus personnel to achieve goals and objectives.