Medical Record Officer

Job Summary

We are seeking a highly organized and detail-oriented Medical Records Officer to join our healthcare team. The successful candidate will be responsible for managing, maintaining, and safeguarding patient medical records, ensuring accurate and timely documentation in compliance with relevant laws, regulations, and standards. The Medical Records Officer will work closely with healthcare professionals to ensure seamless access to patient data while preserving confidentiality and security.

Key Responsibilities:

• Medical Records Management: Maintain, organize, and update patient medical records, ensuring accuracy, completeness, and proper filing in both paper and electronic formats.
  

• Confidentiality and Security: Ensure the confidentiality and security of patient information by adhering to legal and organizational standards, including HIPAA (Health Insurance Portability and Accountability Act) and data protection laws.
  

• Record Retrieval: Efficiently retrieve and release medical records as required, ensuring timely and accurate delivery to authorized healthcare providers and patients.
  

• Data Entry and Quality Control: Enter and update patient information into the electronic health record (EHR) system and ensure data integrity by performing routine audits and error corrections.
  

• Compliance and Documentation: Ensure that all records are maintained in compliance with healthcare regulations and organizational policies. Assist in preparing for audits and inspections as required.
  

• Training and Support: Provide training and guidance to medical staff on proper documentation practices, including the use of EHR systems and record-keeping procedures.
  

• Patient Interaction: Assist patients in obtaining copies of their medical records, explaining the process, and addressing any inquiries related to their documentation

• Retention and Disposal: Oversee the retention and secure disposal of medical records in accordance with legal requirements and organizational policy.
  

• Collaboration: Collaborate with other departments (e.g., billing, administration) to ensure proper integration and management of patient information.
  

Required Qualifications:

• Education: A diploma or degree in Health Information Management, Medical Records, or a related field.
  

• Experience: Proven experience working with medical records.
  

• Knowledge: Understanding of healthcare documentation standards, medical terminology, DOH Policies, and patient privacy laws.
  

• Technical Skills: Proficiency in electronic health record (EHR) systems, medical records software, and MS Office Suite.
  

• Attention to Detail: High level of accuracy and attention to detail in managing medical records.
  

• Communication Skills: Strong written and verbal communication skills to interact with healthcare staff and patients effectively.
  

• Organizational Skills: Ability to handle multiple tasks, prioritize responsibilities, and work efficiently in a fast-paced environment.
  

Desirable Skills:

• Certification in Health Information Management (CHIM, RHIA, or similar) is a plus.
  

• Familiarity with ICD-10 coding, medical billing, and insurance processes is an advantage.