Job Description

Job Title: Medical Records Specialist

Department: Home Health

Reports to: Admissions Coordinator

Job Summary:

The Medical Records Specialist is responsible for ensuring the medical records functions meet State and Federal Regulatory guidelines, and complies with agency policies and procedures. Ensures the duties are completed in a timely and proper manner, either by performing the duties, or by coordinating with staff as needed.

Core Behavior Expectations:

• Ethics: Reaches decisions based on highest ethical standards; fosters a culture of trust and respect for others by behaving in a fair and ethical manner towards others.
• Compliance: Follows generally accepted standards and guidelines for profession/area of work; adheres to company standards of ethics and compliance; performs job duties in accordance with company and state procedures, professional standards and practices and in accordance to relevant laws, regulations and practices.
• Attendance: Maintains appropriate office hours; keeps tardiness and unplanned absences to a minimum.
• Team/Network Building: Works across departmental boundaries and avoids turf issues; exhibits brainstorming techniques and successfully collaborates in a team environment; builds internal and external partnerships to better accomplish goals; maintains good working relationships with co-workers, superiors and public.
• Oral, Written, Non-Verbal Communication: Possesses a solid writing ability demonstrating attention to grammar and spelling; communicates clearly, tactfully, and in a concise manner both verbally and in writing including responding to e-mail, voicemail, and in meetings; uses appropriate communication channels and consults with supervisor about relevant information and potentially sensitive issues.
• Flexible and Adaptable: Adapts to change quickly shortening response time of all processes and systems; modifies plans and goals to meet changing institutional demands; transitions to new business processes; participates in implementing change and applies process improvement changes.
• Critical Thinking: Capitalizes on, contributes to, and identifies opportunities to reduce costs, improve customer service, increase productivity and increase customer satisfaction.
• Productivity/Efficiency: Uses work time effectively; avoids excessive talking, multiple personal phone calls, and internet surfing; keeps appointments on time; responds to external and internal customers (returns phone calls and emails) in a timely manner.
• Time Management: Manages workload; demonstrates ability to prioritize assignments by meeting routine and unexpected deadlines; handles multiple tasks and deadlines.
• Meeting Deadlines: Overcomes obstacles and roadblocks; commits fully to the job and deadlines.

Duties/Responsibilities of the Medical Records Specialist:

Responsibilities of the Medical Records Specialist include, but are not limited to, the following:

• 
  Ensures all medical documentation is filed in the patient’s closed and/or open clinical records (hard copies and computer records) in a proper and timely manner
• Conducts ongoing quality assurance activities with all medical records in department to ensure accuracy and completeness of clinical records processing
• Develops organizational tools to facilitate and incorporate accountability for all medical records
• Identifies and informs supervisor of discrepancies if found related to the medical records functions requiring completeness and regulatory compliance, and if discrepancies are discovered develops immediate corrective actions to meet the state and federal regulatory requirements for accuracy and completeness.
• Takes initiative to enhance record department procedures and capabilities
• Ensures all physician verbal orders and other orders received via facsimile (to include Plans of Care, Certificates of Terminal Illness) are signed by the appropriate ordering physician, and provides follow-up for all missing and unsigned paperwork.
• Ensures safeguarding of medical records in accordance with the Privacy Act. Maintains HIPAA compliance regarding any patient and agency records.
• Audit for completion and close discharged patient records within 14 days of discharge per agency procedure ensuring all documentation is complete and all documents are signed and dated by the appropriate discipline.
• Provides medical record information, to include computer generated data, to all staff as necessary
• Prepares and transmits basic correspondence, uses office equipment
• Answers the phone and directs phone calls appropriately
• Performs other duties as assigned
• Will participate in Quality Assurance Performance Improvement as required
• Insurance verification on referrals

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Required Skills/Abilities:

• Demonstrates good verbal and written communication and customer relations skills.
• Demonstrates autonomy, organization, assertiveness, flexibility, and cooperation in performing job responsibilities.
• Knowledge of medical terminology
• Computer Literacy
• Intermediate Typing Skills
• Knowledge of office machines
• Excellent phone skills with emphasis on customer service
• Organization skill

Education and Experience:

High school diploma or equivalent.

2 years experience in a medical office, hospital, outpatient clinic, or other health care settings. Home health or hospice experience preferred.

Physical Requirements:

Prolonged periods of sitting and standing.

Must be able to lift up to 15 pounds at times.

Company Description

When you become part of our exceptional team you’ll have the satisfaction of knowing your work actually makes a difference.

At Affirmation Home Health you’ll become part of the extraordinary lives of the people who live in and around Richmond VA, and a passionate, close-knit team of professionals who provide support from all levels of the organization. As we constantly seek to learn and improve our services, your ideas and input will be openly valued and respected. You’ll have opportunities to give back to the greater community.

We are growing in two of the strongest sectors of the employment market — healthcare and hospitality.

Vaccination Requirement Statement

Employees hired for this position will be required to follow Affirmation Home Health’s company-wide policies of being or becoming fully vaccinated against COVID-19 including the booster when eligible, each subject to potential accommodation for medical reasons or religious beliefs.