Medical Records Specialist

2 months ago

Fort Myers, United States TeleSpecialists LLC Full time
Job DescriptionJob Description

Job Title: Medical Record Specialist

This position is 100% in office at our Ft. Myers home office

The Medical Record Specialist is responsible for maintaining accurate and confidential medical records for patients. This role involves organizing, updating, and managing patient health information in accordance with regulatory standards and facility policies.

Responsibilities:

1. Record Management:

 Collect, organize, and maintain patient medical records electronically or in paper form.

 Ensure accuracy, completeness, and confidentiality of all medical records.

 Update patient information, including demographics, medical history, treatments, and procedures.

2. Coding and Indexing:

 Assign appropriate diagnostic codes and procedural codes to patient records for billing and insurance purposes.

 Index and catalog medical records using standard classification systems such as ICD-10 and CPT.

3. Data Entry and Retrieval:

 Enter patient information into electronic health record (EHR) systems accurately and efficiently.

 Retrieve patient records as needed for healthcare providers, administrators, and other authorized personnel.

4. Compliance and Quality Assurance:

 Ensure compliance with regulatory requirements, such as HIPAA, to protect patient privacy and confidentiality.

 Conduct regular audits of medical records to maintain accuracy and quality standards.

5. Collaboration:

 Collaborate with healthcare providers, nurses, administrative staff, and other personnel to ensure accurate and timely record management.

 Assist in the coordination of patient care by providing necessary health information to authorized individuals.

6. Customer Service:

 Assist patients and their families with inquiries related to medical records, including requests for copies, release of information, and clarification of documentation.

Qualifications:

 High school diploma or equivalent; associate's degree or certification in Health Information Management preferred.

 Knowledge of medical terminology, anatomy, and physiology.

 Proficiency in electronic health record (EHR) systems and medical coding software.

 Strong attention to detail and organizational skills.

 Ability to maintain confidentiality and adhere to ethical standards.

 Excellent communication and interpersonal skills.

 Prior experience in medical records management or healthcare administration is desirable.

Working Conditions: Medical Record Specialists typically work in healthcare facilities such as hospitals, clinics, nursing homes, or medical offices. They may spend long hours sitting at a computer workstation and may need to lift boxes or files occasionally. This role requires adherence to strict privacy and confidentiality guidelines.

This job description may vary depending on the specific needs of the healthcare facility and the level of responsibility assigned to the Medical Record Specialist.

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