Medical Records Administration Specialist

2 weeks ago


Bethesda, United States National Institutes Of Health Full time

Securing and managing confidential or sensitive information within area of control in accordance with established laws, regulations, and guidelines including the Privacy Act of 1974 including processing of release of medical information requests.
Consulting and collaborating with investigators and clinical care staff to ensure medical record documentation is accurate, promotes patient safety, and meets regulatory requirements.
Assisting with analyzing record documentation to assure the presence of all required component parts.
Utilizing information from record analysis process to provide feedback to clinicians regarding medical record documentation practices.
Analyzing trends in issues related to clinical research documentation to assist in the development of educational programs and materials to ensure medical records are consistently complete, accurate and promote patient safety.
Conducting queries with medical staff to ensure medical record documentation is consistent and adequate to ensure that the final diagnosis accurately reflects the care and treatment rendered.
Tracking and identifying rare disease data related to NIH intramural protocols.
Assisting in the development, maintenance, evaluation and adaptation of systems and procedures for the storage, retrieval and utilization of coded diagnostic and procedural data for use by hospital and institute administrative and patient care staff.
Assisting with periodic audits of coding of records.
Coding diagnostic and procedural encounters by selecting and assigning codes from the current version of several coding systems.



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