Job Description

The Medical Records Associate will be responsible for maintaining and managing patient medical records in compliance with regulatory requirements and practice policies. The ideal candidate will have strong organizational skills, attention to detail, and experience in medical records management in a healthcare setting.

Responsibilities:

• Medical Records Management: Maintain accurate and up-to-date patient medical records, including electronic health records (EHR), paper charts, and other documentation systems. Organize and file patient medical records according to established protocols, including filing, scanning, and indexing documents in electronic and paper formats.
• Record Retrieval and Release: Retrieve patient medical records for healthcare providers, clinical staff, and administrative staff as needed for patient care, referrals, and medical consultations. Process requests for release of medical records in compliance with HIPAA regulations and practice policies, ensuring patient confidentiality and privacy.
• Record Review and Auditing: Review patient medical records for accuracy, completeness, and compliance with documentation standards, regulatory requirements, and coding guidelines. Assist with internal record audits, external record requests, and compliance reviews to ensure quality assurance and regulatory compliance.
• Data Entry and Documentation: Enter and update patient demographic information, medical histories, test results, and other clinical data accurately in electronic health records (EHR) or practice management systems. Maintain documentation of patient encounters, medical procedures, and treatments in accordance with practice protocols and regulatory requirements.
• Release of Information: Respond to requests for release of information from patients, healthcare providers, insurance companies, and other authorized entities, ensuring compliance with legal and regulatory requirements. Coordinate with billing staff and insurance companies to provide supporting documentation for insurance claims, pre-authorizations, and reimbursement purposes.
• Communication and Collaboration: Communicate effectively with healthcare providers, clinical staff, administrative staff, and external stakeholders regarding medical records management, documentation requirements, and record retrieval processes. Collaborate with interdisciplinary healthcare team members to facilitate efficient and accurate management of patient medical records.

Requirements

• High school diploma or equivalent required; Associate's degree or certification in medical records technology or healthcare administration preferred.
• Minimum of 1-2 years of experience in medical records management, preferably in a healthcare or medical practice setting.
• Strong knowledge of medical terminology, documentation standards, and regulatory requirements related to medical records management.
• Proficiency in using electronic health records (EHR) systems and practice management software for medical records management and data entry.
• Excellent organizational skills, attention to detail, and accuracy in managing and maintaining patient medical records.
• Strong communication and interpersonal skills, with the ability to interact effectively with patients, healthcare providers, and administrative staff.
• Ability to maintain confidentiality, privacy, and security of patient health information in compliance with HIPAA regulations and practice policies.