Medical Records Specialist

Our Medical Records Specialist will ensure the accurate, secure, and efficient management of patient health information. Are you dedicated to supporting healthcare providers in delivering high-quality care by maintaining the integrity and confidentiality of medical records? Through your data governance and compliance expertise, you strive to enhance patient safety, facilitate seamless communication within our team, and contribute to informed decision-making. With a commitment to continuous improvement and a patient-centered approach, you will empower our organization to uphold the highest standards of health information management.

Key Responsibilities

1. Medical Records Management:

o Maintain and organize client medical records, including psychological evaluations, treatment plans, progress notes, intake assessments, discharge summaries, and other relevant documentation.

o Ensure all medical records are complete, accurate, and legible, with proper coding, signatures, and dates as required by agency standards and regulatory guidelines.

o Safeguard confidentiality and privacy of client medical records in accordance with HIPAA regulations and other applicable laws.

o Ensure records are stored securely, both electronically and physically, and accessible only to authorized personnel.

2. Compliance and Documentation:

o Review medical records for accuracy and completeness, making sure that all necessary documentation is in place before files are closed or transferred.

o Monitor records for compliance with HIPAA and other healthcare privacy laws, ensuring all documentation adheres to confidentiality standards.

o Assist with the preparation of records for audits or compliance reviews, ensuring that all required documentation is up to date and organized for inspection.

o Respond to requests for information from authorized personnel, such as physicians, case managers, insurance companies, and legal entities, in accordance with privacy regulations.

3. Data Entry and Electronic Medical Record (EMR) Systems:

o Input new client information into the agency’s Electronic Medical Records (EMR) system (coming soon/training will be available) and ensure all fields are populated accurately and completely.

o Update existing client records in the EMR system/Paperback as necessary, ensuring any changes to treatment plans, progress notes, or other critical documentation are reflected promptly.

o Troubleshoot and resolve any issues related to the EMR system, collaborating with IT or technical support when needed.

o Conduct regular audits of the EMR system to ensure all client information is complete, accurate, and in compliance with agency policies.

4. Record Retrieval and Filing:

o Retrieve and prepare medical records for case managers, counselors, or other authorized healthcare providers when requested.

o Maintain an efficient and systematic filing system for physical and electronic records, ensuring ease of access and retrieval when needed for client care or legal purposes.

o Archive older records according to agency policies, ensuring that all records are retained and disposed of in a manner that meets legal and regulatory requirements.

o Ensure the timely transfer of records between departments or external entities as required.

5. Confidentiality and Security:

o Ensure all client records are handled with the utmost confidentiality and in accordance with HIPAA and other legal requirements related to health information privacy.

o Safeguard against unauthorized access to client records and ensure that information is shared only with authorized individuals as permitted by the client and agency policies.

o Participate in the development and implementation of internal policies and procedures related to record-keeping and privacy.

6. Collaboration and Communication:

o Work closely with clinical staff, case managers, and other departments to ensure that all required documentation is complete, timely, and accurate.

o Assist healthcare providers with accessing specific client records or documentation when necessary to ensure continuity of care.

o Communicate effectively with clients, ensuring that any requests for copies of their records or information are processed promptly and in compliance with legal requirements.

o Act as a liaison between the agency and external partners such as healthcare facilities, insurance providers, and legal entities for medical records requests.

7. Training and Development:

o Participate in regular training to stay current with developments in medical record-keeping, privacy laws, and new technologies used in managing client information.

o Train new staff on the proper handling, entry, and retrieval of medical records to ensure compliance with agency protocols and legal requirements.

o Stay informed about trends in healthcare documentation practices and suggest improvements to increase efficiency and accuracy in record management.

8. General Administrative Support:

o Perform general clerical duties such as answering phones, managing emails, scheduling appointments, and maintaining office supplies related to medical records.

o Assist with special projects related to client records or reporting as assigned by the Program Director or other senior staff members.

o Support the team in ensuring the smooth operation of the office and contribute to a positive work environment.

Qualifications:

· High school diploma or equivalent required; an associate’s degree or higher in healthcare administration, medical records management, or a related field is preferred.

· Certification in medical records management or health information management (e.g., RHIT, CCA, or similar certifications) is a plus.

· Proven experience in managing medical records, preferably in a mental health or healthcare setting.

· Strong knowledge of HIPAA regulations and healthcare privacy laws.

· Experience working with Electronic Medical Record (EMR) systems; familiarity with [specific EMR software used in the organization] preferred.

· Excellent attention to detail and organizational skills with the ability to prioritize tasks effectively.

· Strong written and verbal communication skills.

· Ability to maintain confidentiality and exercise discretion in handling sensitive client information.

· Proficient in Microsoft Office Suite (Word, Excel, Outlook) and basic office equipment.

· Ability to work both independently and collaboratively in a team-oriented environment.

Working Conditions:

· The position will be based in an office environment with some flexibility for remote work depending on organizational policies.

· The role involves prolonged periods of sitting and working on a computer.

· Occasional lifting of files and office supplies up to 25 pounds.

· May require other tasks outside of Medical Records/Auditing

(For immediate consideration, please submit your cover letter and resume to jpexec@reliantsolutionsllc.onmicrosoft.com - Our Recruiting Specialist will follow up within 24 hours of your submission.)

Job Types: Full-time, Part-time, Contract, Temporary

Expected hours: 40 per week

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Ability to Commute:

• Petersburg, VA 23805 (Required)

Ability to Relocate:

• Petersburg, VA 23805: Relocate before starting work (Required)

Work Location: In person