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Medical Records Compliance Specialist
2 months ago
JOB SUMMARY:
The Medical Records Compliance Specialist is responsible for compiling, scanning, processing, and maintaining medical records in accordance with medical administrative, ethical, legal, and regulatory standards. This role utilizes an electronic health record (EHR) system for data inquiries, data entry, and report generation, while ensuring the appropriate release of medical information.
ESSENTIAL FUNCTIONS:
1. Conducts thorough analysis of EHR for each discharged patient across various care settings, including inpatient, observation, same-day surgery, and emergency departments, to ensure the completeness and accuracy of medical charts.
2. Ensures that all records comply with standards established by regulatory bodies and the organization.
3. Abstracts essential data for collection, including primary, secondary, and consulting providers, as well as accurate admission and discharge timestamps.
4. Maintains the provider deficiency database on a daily basis, addressing and resolving any identified deficiencies.
5. Utilizes current deficiency database information to log deficiencies in an Excel format, which is shared during medical records committee meetings and with regulatory agencies.
6. Communicates effectively with healthcare providers and professionals regarding any missing or unclear documentation.
7. Notifies the Health Information Services (HIS) director or team leader regarding records that remain deficient over an extended period.
8. Completes quality assurance studies and projects as needed.
9. Updates and revises policies and procedures upon request.
10. Scans all paper-based records into the EHR, ensuring proper categorization in designated folders.
11. Generates daily reports to monitor patients assigned new medical record numbers, retaining and deleting records as necessary.
12. Scans Advance Directives into patient charts and updates the relevant database.
13. Responds to phone inquiries in a prompt and courteous manner.
14. Conducts daily rounds to gather information on all discharged patients from care floors.
15. Abstracts and submits birth data to the state registry for all newborns.
16. Upholds the confidentiality of all medical information.
17. Manages the release of information to patients, insurance companies, other providers, and authorized entities, adhering to HIPAA guidelines.
18. Reviews authorization requests to ensure compliance with release specifications, particularly for sensitive information.
19. Strives to ensure timely release of information for patient care and within five business days for all other requests.
20. Retrieves paper-based charts for historical information as needed.
21. Organizes and maintains NST strips received from obstetrics, ensuring they are orderly and accessible for providers.
22. Compiles and maintains daily admission and discharge statistics, sharing this information with relevant departments at the end of each month.
23. Performs mailroom duties as required.
24. Engages in ongoing educational training and professional development.
25. Undertakes additional related duties as assigned, in alignment with the best interests of the organization.
26. Actively participates in all employee safety program initiatives.
27. Collaborates as a member of the HIS team to foster a culture of safety within the department and across the organization.
