Medical Records Specialist

Principal Accountabilities:

• Process clinical documentation to support the clinical team's patient and billing information needs.
• Scan and attach documents and photos to the appropriate electronic medical record in accordance with department guidelines and within acceptable productivity standards.
• Ensure that patient chart and electronic patient record information is accurate, current, and complete.
• Identify faxes and documentation that should be triaged to the appropriate Clinical Managers or other leaders for immediate review.
• Complete workflow in electronic medical records related to medical records, orders, and claims processing.

Revenue Cycle Operations:

• Monitor and track progress of claim holds and ensure claims processing is within department guidelines.
• Follow up with hospital liaisons, staff, and physicians to obtain complete and signed orders and documentation within required time frames.
• Complete chart audits to ensure agency standards are met, including but not limited to:
  • Ensure the visits and frequency match the orders in the patient medical record.
  • Verify required supporting documentation is present.
  • Notify appropriate staff regarding changes in frequency and additional documentation needed.
  • Ensure visits are appropriately invoiced for services, and the amount of “in-home visit time” rendered is accurate as documented in the patient medical record.
• Complete End of Episode review for Non-Medicare clients.
• Assist with processing ADRs and payer appeals.

Medical Records Management and Release of Information:

• Complete accurate and efficient data entry in the electronic medical record as requested by the manager.
• Enter confirmation that signed documents have been received.
• Complete requests for subpoenaed documentation and process according to agency policy and HIPAA regulations.
• Retrieve and copy medical records as requested by Administrators or Clinical Managers, following agency policy.
• Assist in the "Purge List" report and work with locations to purge charts from permanent storage; maintain accurate records of this process.

Quality Management:

• Protect the confidentiality of patient and agency information through effective controls and supervision of clinical records.
• Ensure clinical record systems comply with state, federal, and accreditation requirements.

Customer Service:

• Relate with tact and respect at all times to internal and external customers. Actively build positive relationships with both internal and external customers.
• Use effective interpersonal and communication skills to promote customer service with internal and external customers.
• Facilitate cross-service line collaboration and strengthen communications and problem-solving to support continuity of care.

Education:

• Equivalent experience will be accepted in lieu of the required degree or diploma.
• HS Diploma or equivalent education/experience.
• Graduation from an accredited program of secretarial science is preferred, and related coursework in business skills is preferred.
• Associate's degree in Office Management, Medical Records, Business, or a related field is strongly desired.

Preferred Experience:

• 2 years of experience in an office environment, preferably in a healthcare organizational setting.
• Previous experience in medical records preferred.
• Previous experience in home care preferred.

Skills and Knowledge:

• A working knowledge of medical and home care terminology is strongly preferred.
• Knowledge of general office practices and procedures, including filing, record-keeping, photocopying, and faxing.
• Experience with computer data entry at least 50 WPM.
• Proficiency in the efficient use of electronic medical record systems (after training and the introductory period).
• Willingness and ability to learn new computer software with training provided.
• Ability to follow a defined list of tasks and established procedures, completing them in a timely fashion.
• Ability to adapt to increased workflow when the census is higher and recognize the urgency of each task.
• Excellent verbal and written communication skills in all interactions with patients and staff, demonstrating excellent customer service.