SUMMARY :

Medical Records Specialist is responsible for the entering and / or processing of documents, clinical information, and medical orders, as well as the maintenance patients’ electronic records.

The Medical Records Specialist also assumes duties of the Team Assistant as assigned.

MINIMUM QUALIFICATION STANDARDS :

I. Education :

High school diploma or equivalent

II. Experience :

Minimum of two years office experience, preferably in a home care environment

PERFORMANCE REQUIREMENTS :

I. Performance Standards :

• Audits and processes physician signed plans of care and interim orders ensuring that they are complete and accurate
• Receives, processes, and tracks documents such as admission forms, consent forms, Medicare Non-Coverage Notices, and Home Health Advance Beneficiary Notices

Receives, prepares, and submits both internal and external record requests

• Reminds clinicians and notifies clinical team managers of overdue or missing documentation. Contacts clinicians as needed to clarify orders and other documents
• Enters clinical data into the electronic record, including clinical notes and signed medical orders, as requested
• Corrects or assists with correcting documents according to organization’s procedures
• Acts as a resource to staff and managers for questions related to interim orders, order processing, and other clinical record documents.

Assists clinicians to complete orders, forms, and records in conformance with regulations

• Refers non-routine questions and situations related to electronic medical records to supervisor, clinical team manager, or Accounts Receivable, in order to acquire a solid understanding of regulations and clinical record requirements
• Runs reports as assigned
• Any other duties as assigned by supervisor

Last updated : 2024-03-22