What are the responsibilities and job description for the Clinical Medical Records Specialist position at Soni Family Practice, PLLC?
Company: SFP Health Group
Job title: Clinical Medical Records Specialist
Division/Department: Clinic Operations
Reports to: Office Manager
Job Summary:
The Clinical Medical Records Specialist is responsible for managing and maintaining patient records in compliance with legal, ethical, and regulatory standards. This role involves ensuring accurate documentation, secure storage, and efficient retrieval of medical records, supporting the clinical staff in delivering high-quality patient care.
Essential Duties and Responsibilities:
Accurately maintain and update patient medical records, ensuring compliance with HIPAA and other relevant regulations.
Organize and file medical documents, such as charts, test results, and treatment plans, in both electronic and paper formats.
Retrieve and provide medical records as requested by authorized personnel in a timely manner.
Input and verify patient information into electronic health record (EHR) systems.
Ensure all medical records are complete, accurate, and properly formatted.
Document any corrections, amendments, or updates to patient records according to established protocols.
Adhere to all federal, state, and local regulations regarding medical records management and patient privacy.
Monitor and audit records to ensure compliance with legal standards and organizational policies.
Handle sensitive information with the utmost confidentiality and discretion.
Collaborate with healthcare providers, administrative staff, and external agencies to facilitate the flow of medical records and information.
Respond to inquiries and requests for patient information from healthcare providers and authorized third parties.
Assist in training and guiding other staff members on proper records management procedures.
Participate in quality improvement initiatives related to medical records management.
Identify areas for improvement in records management processes and suggest enhancements.
Conduct regular audits to ensure the accuracy and integrity of patient records.
Provide technical support for electronic health record systems, troubleshooting issues as they arise.
Assist with the implementation of new EHR systems or upgrades.
Knowledge, Skills, and Abilities:
Proficient in electronic health record (EHR) systems and medical coding.
Strong attention to detail and organizational skills.
Excellent communication skills, both verbal and written.
Ability to handle sensitive information with confidentiality and professionalism.
Familiarity with HIPAA regulations and medical terminology.
Qualifications:
1-2 years of medical background.
MA certification or associate degree in medicine.
Athena knowledge preferably but no require.
Physical & Mental Requirements: (check all that apply)
Ability to stand or sit for extended periods of time.
Ability to receive and comprehend instructions verbally and/or in writing.
Ability to use logical reasoning for simple and complex problem solving.
Occasionally requires exposure to communicable diseases or bodily fluids.
Occasional travel for clinic activities may be required.
The information listed above is not comprehensive of all duties/responsibilities performed. This job description
is not an employment agreement or contract. Management has the exclusive right to alter this job description
at any time without notice.
Job title: Clinical Medical Records Specialist
Division/Department: Clinic Operations
Reports to: Office Manager
Job Summary:
The Clinical Medical Records Specialist is responsible for managing and maintaining patient records in compliance with legal, ethical, and regulatory standards. This role involves ensuring accurate documentation, secure storage, and efficient retrieval of medical records, supporting the clinical staff in delivering high-quality patient care.
Essential Duties and Responsibilities:
Accurately maintain and update patient medical records, ensuring compliance with HIPAA and other relevant regulations.
Organize and file medical documents, such as charts, test results, and treatment plans, in both electronic and paper formats.
Retrieve and provide medical records as requested by authorized personnel in a timely manner.
Input and verify patient information into electronic health record (EHR) systems.
Ensure all medical records are complete, accurate, and properly formatted.
Document any corrections, amendments, or updates to patient records according to established protocols.
Adhere to all federal, state, and local regulations regarding medical records management and patient privacy.
Monitor and audit records to ensure compliance with legal standards and organizational policies.
Handle sensitive information with the utmost confidentiality and discretion.
Collaborate with healthcare providers, administrative staff, and external agencies to facilitate the flow of medical records and information.
Respond to inquiries and requests for patient information from healthcare providers and authorized third parties.
Assist in training and guiding other staff members on proper records management procedures.
Participate in quality improvement initiatives related to medical records management.
Identify areas for improvement in records management processes and suggest enhancements.
Conduct regular audits to ensure the accuracy and integrity of patient records.
Provide technical support for electronic health record systems, troubleshooting issues as they arise.
Assist with the implementation of new EHR systems or upgrades.
Knowledge, Skills, and Abilities:
Proficient in electronic health record (EHR) systems and medical coding.
Strong attention to detail and organizational skills.
Excellent communication skills, both verbal and written.
Ability to handle sensitive information with confidentiality and professionalism.
Familiarity with HIPAA regulations and medical terminology.
Qualifications:
1-2 years of medical background.
MA certification or associate degree in medicine.
Athena knowledge preferably but no require.
Physical & Mental Requirements: (check all that apply)
Ability to stand or sit for extended periods of time.
Ability to receive and comprehend instructions verbally and/or in writing.
Ability to use logical reasoning for simple and complex problem solving.
Occasionally requires exposure to communicable diseases or bodily fluids.
Occasional travel for clinic activities may be required.
The information listed above is not comprehensive of all duties/responsibilities performed. This job description
is not an employment agreement or contract. Management has the exclusive right to alter this job description
at any time without notice.
