Records

About the Role:

The Records position within the Health Care and Social Assistance industry is pivotal in ensuring the accurate management, organization, and security of patient and organizational records. This role involves maintaining comprehensive documentation that supports clinical, administrative, and regulatory functions, thereby facilitating seamless healthcare delivery and compliance with legal standards. The successful candidate will be responsible for the systematic collection, storage, retrieval, and protection of sensitive health information, ensuring confidentiality and integrity at all times. By managing records efficiently, this role directly contributes to improved patient outcomes, operational efficiency, and adherence to healthcare regulations such as HIPAA. Ultimately, the Records professional acts as a critical link between healthcare providers, patients, and regulatory bodies by maintaining trustworthy and accessible health information systems.

Minimum Qualifications:

• High school diploma or equivalent required; Associate degree or higher in Health Information Management or related field preferred.
• Experience working with electronic health records (EHR) systems or medical records management.
• Knowledge of healthcare privacy laws and regulations, including HIPAA compliance.
• Strong organizational skills with the ability to manage multiple tasks and maintain attention to detail.
• Proficiency in basic computer applications such as Microsoft Office Suite.

Preferred Qualifications:

• Certification as a Registered Health Information Technician (RHIT) or Certified Medical Records Technician (CMRT).
• Experience in a healthcare setting such as hospitals, clinics, or social assistance organizations.
• Familiarity with medical terminology and coding systems like ICD-10 and CPT.
• Advanced skills in health information systems and data analytics tools.
• Excellent communication skills to effectively collaborate with multidisciplinary teams.

Responsibilities:

• Maintain and update patient records and healthcare documentation with accuracy and attention to detail.
• Ensure compliance with federal, state, and organizational policies regarding health information privacy and security.
• Coordinate with healthcare providers and administrative staff to collect and verify necessary documentation.
• Manage electronic health record (EHR) systems, including data entry, quality control, and troubleshooting.
• Prepare and generate reports related to patient data, billing, and regulatory requirements.
• Assist in audits and inspections by providing accurate records and documentation as required.
• Train and support staff on proper record-keeping procedures and use of health information systems.
• Implement and monitor data retention schedules and secure disposal of records in accordance with legal guidelines.

Skills:

The required skills enable the Records professional to accurately input, organize, and retrieve patient data, ensuring that all information is current and compliant with healthcare regulations. Proficiency with electronic health record systems is essential for daily operations, allowing for efficient data management and reporting. Knowledge of privacy laws such as HIPAA guides the secure handling and confidentiality of sensitive information. Preferred skills, including certification and familiarity with medical coding, enhance the ability to interpret and manage complex health data, improving the quality and usability of records. Strong communication and organizational skills facilitate collaboration with healthcare providers and administrative staff, ensuring that records support clinical decision-making and regulatory compliance effectively.