Join our administrative team as a Medical Records Specialist, where you will play a foundational and non-negotiable role in ensuring the precision and protection of all patient health information (PHI). Your commitment to meticulous accuracy and strict adherence to confidentiality protocols is essential, as the integrity of our medical records underpins all clinical, operational, and financial activities across our organization.

Job Description

The Medical Records Specialist is responsible for the systematic organization, maintenance, security, and accessibility of patient medical records. This critical role involves processing, analyzing, coding, and verifying health information for completeness, accuracy, and compliance with strict regulatory standards (including privacy laws). You will be the guardian of our data integrity, ensuring that all clinicians have timely access to precise records necessary for high-quality patient care.

Responsibilities:

• Record Integrity and Accuracy: Review patient records (both paper and electronic, including EPIC, Cerner, or other EHR systems) to ensure all documentation is complete, accurate, signed, and properly filed or electronically indexed. Accuracy is paramount in all tasks.

• Data Coding and Classification: Assign standardized codes (e.g., ICD-10-CM, CPT, HCPCS) to diagnoses and procedures using established classification systems, ensuring proper documentation supports the assigned codes for billing and statistical purposes.

• Health Information Management (HIM): Manage the release of information (ROI) process, ensuring that requests for medical records are processed efficiently, securely, and in full compliance with legal requirements and patient consent protocols.

• Scanning and Indexing: Organize and prepare hard-copy documents for electronic scanning, and accurately index and link digitized documents into the correct patient's Electronic Health Record (EHR).

• Compliance and Confidentiality: Strictly adhere to all national and organizational regulations regarding patient confidentiality and data security, including managing record retention and destruction schedules according to legal and policy requirements.

• Data Quality Audits: Perform routine audits of patient charts and departmental records to identify and correct documentation discrepancies, incomplete records, or potential coding errors, proactively supporting data quality initiatives.

• Troubleshooting and Support: Assist clinical staff and internal departments with questions related to documentation standards, record access, and correcting or amending patient records in the EHR system.

• System Proficiency: Effectively navigate and utilize the organization's EHR and other related health information management systems to retrieve, update, and secure patient data.

Requirements:

• Education: Associate Degree in Health Information Technology (HIT), Medical Records Science, or a related administrative/healthcare field, or equivalent experience.

• Certification (Highly Preferred): Certification as a Registered Health Information Technician (RHIT) or Certified Coding Associate (CCA/CCS) is strongly advantageous.

• Experience: Proven experience (2+ years) working within a hospital or large clinic setting specifically handling medical records and health information management.

• Technical Knowledge: Comprehensive understanding of medical terminology, anatomy, physiology, and pharmacology, especially as they relate to clinical documentation and coding.

• EHR Proficiency: Demonstrable proficiency in working with Electronic Health Record (EHR) systems; familiarity with major platforms (e.g., Epic, Cerner) is a significant asset.

• Regulatory Knowledge: In-depth knowledge of privacy and security regulations governing health information (e.g., relevant Australian legislation or comparable international standards).

• Meticulous Attention to Detail: An absolute commitment to accuracy in data entry, coding, filing, and auditing is essential to success in this role.

• Ethical Conduct: Unwavering commitment to maintaining patient confidentiality and handling sensitive information with the highest level of integrity.

• Organizational Skills: Excellent time management and organizational abilities to manage a high volume of documentation and prioritize tasks effectively.

Your dedicated efforts as a Medical Records Specialist will be instrumental in maintaining the operational backbone of our organization, ensuring we consistently deliver care based on precise, protected, and reliable health data.