Position Summary

The Medical Record Specialist is responsible for multiple aspects of the day to day activities of the Health Information Management Department. Some of these items include the receipt, verification, review and follow-up on all requests for copies of patient’s medical information; serving as the Department Receptionist with responsibility for helping walk-ins, answering phones, checking and answering faxes, checking and answering ROI email and opening, sorting and responding to mail. Helps with maintaining the hospital Release of Information tracking system for releases of patient protected health information. May be required to retrieve, distribute and file records. May help with Scanning and Indexing records. May help with completing Birth Registrations. Responsible for ensuring that all HIPAA guidelines are met with each records request and that the information released is appropriate and accurate. Performs within the prescribed limits of the hospital’s/departments Ethics and Compliance program. Responsible to detect, observe and report compliance variances to the Director of Health Information Management or upward through the chain of command, the Compliance Office or hospital hotline.

Essential Duties & Responsibilities:

Responsible for receiving, verifying, reviewing, recording and tracking of medical records requests

Responsible for opening, sorting, responding to mail

Responsible for assisting with maintaining the Medical Center’s Master Patient Index and assisting with the medical record deficiency system.

Works with outside imaging vendor to ensure all records requests are processed and submitted timely.

Reviews request for medical records to identify dates of service, provider and specific clinical documents requested.

Works extensively in the electronic health record and de-centralized electronic databases to locate specific clinical documents for the purpose of fulfilling a request.

Reviews patient authorizations to validate HIPAA required elements and validate legal authority of requestor.

Assists with maintaining master patient index integrity, medical record number merges, un-merges and medical record number assignments electronically.

Assist with Birth Certificates as needed.

Assists with Scanning and Indexing as needed.

Performs all other duties as assigned by management.

Detailed working knowledge and ability to apply HIPAA rules, North Carolina General Statutes, and other State and Federal laws regarding patient privacy.

Qualifications

High School Diploma or equivalent required. Associate degree or Certification in Medical Office/Medical Records preferred. One year of experience in release of information in hospital or physician’s office setting is required. Notary preferred.

Must have good communication and customer service skills. Must be able to use considerable initiative and judgment. A strong knowledge of Federal and North Carolina statutes in release of information is required. Must be able to work under pressure and in conditions of frequent interruptions. Must have computer and Microsoft Office skills. Computer skills with the ability to navigate and query multiple electronic record systems. Good organizational skills, excellent investigative/analytic skills with detail orientation, and strong follow-through capabilities. Able to meet deadlines, work independently, set priorities and maintain confidentiality. Ability to work calmly and efficiently in high-pressure situations.