Medical Records Specialist - Acute

The Pavilion At Williamsburg Place - Williamsburg, VA

Full-time - Entry Level

Williamsburg, VA

Hospitals

About the position

The Medical Records Specialist at The Pavilion at Williamsburg Place is responsible for the qualitative management of medical records, ensuring accuracy and compliance with established policies and regulations. This role involves the preparation, assembly, and analysis of medical records, as well as the assignment of diagnostic codes for billing and reporting purposes.

Responsibilities

• Prepares and assembles medical records.
• Organizes and analyzes medical records for accuracy and completeness.
• Establishes and maintains chart control, access, and storage relating to the custody of charts and documents.
• Receives requests for information from medical records of patients in various formats.
• Logs in and out all incoming requests for release of information.
• Assures authorizations are properly executed when responding to requests for medical information.
• Manages provided transcription services and resolves issues/errors regarding reports.
• Ensures files are stored in the designated area according to storage procedures.
• Pulls charts as requested for audits, peer review, and other processes.
• Processes reports for delivery of records for correspondence.
• Compares signatures and forwards standard letters to requesting parties.
• Performs quantitative and qualitative analysis of discharge records and monitors completion of deficiencies.
• Abstracts clinical information to maintain indices within specified time frames.
• Identifies records for quality review monitoring or audits and assists in data retrieval.
• Files pertinent clinical data in the appropriate chart and manages discharge charts.
• Purges and inventories medical records for off-site storage.
• Maintains Master Patient Index of all clients admitted into the facility.
• Prints and delivers medical records forms to patient units.
• Picks up discharge records from patient units.
• May perform coding functions using ICD-10 and/or CPT.

Requirements

• High school diploma or equivalent required.
• A minimum of one year experience in Medical Records in a psychiatric setting required.
• Prior experience as an abstractor in a health information management or related healthcare field is preferred.

Nice-to-haves

• Experience with ICD-10 coding and CPT coding is a plus.

Benefits

• Comprehensive benefit plan
• Competitive salary commensurate with experience and qualifications