Medical Records Specialist

POSITION TITLE: Medical Records Specialist

REPORTS TO: Health Information Manager 

DIRECT REPORTS: None 

FLSA STATUS: Non-exempt; regular full-time; employment-at-will position. 

SCHEDULE: The work schedule will generally conform to that of a full-time Monday-Friday 40-hour-per-week schedule to be performed within the Center’s hours of operation. 

PURPOSE: Completes tasks in the Medical Records office to ensure that medical records are protected and only released in accordance with applicable Federal and State regulations. 

JOB FUNCTIONS:  

1. Process requests for medical records in a timely manner, ensuring that medical records are provided to outside agencies within an acceptable time frame, with only the minimum necessary information released, and with the consent of the client or legal guardian when required.
2. Ensure the confidentiality and security of client records by storing records securely, ensuring the department is locked, and records are not accessible when staff are not in the department.  Report any potential or actual breach of privacy to the organizational Privacy Officer, and appropriate department manager.
3. Assist with maintaining paper charts in accordance with organizational policies and procedures.
4. Assist with Utilization Review processes as needed and as assigned.
5. Report suspected or confirmed documentation problems, delays, or errors. Stay alert to the overall quality of clinical documentation and report any substandard entries to the HIM Manager.
6. Make sure that all treatment plans are reviewed and approved by all parties involved and documented per organizational standards. Help providers maintain up-to-date master treatment plans.
7. Documents all records released by Kanza Mental Health and Guidance Center in the client’s record in accordance with organizational standards.
8. Collaborate with clients and other departments to ensure current Releases of Information (ROI) are available in the client’s electronic health record, and update/send ROIs for client signatures as needed.
9. Document external ROIs in the client’s electronic health record, and scan information into the electronic health record in accordance with organizational standards.
10. Collaborate with departments to re-engage clients in services as needed, to communicate with clients who are no longer actively engaged in services, and to discharge clients and close the client chart when appropriate.
11. Assists with the destruction of client charts and documentation of destruction in accordance with organizational standards.
12. Manages incoming and outgoing faxes, ensuring that appropriate party(s) are provided with faxed communications as indicated.
13. Participate in continuous staff training regarding the privacy and security of clinical records, how to access records, and documentation expectations.
14. Provide regular reports and updates to the HIM Manager when needed.
15. Assist with maintaining control over all incoming and outgoing consumer records and other clinical documentation.
16. Monitor for gaps in treatment or unmet client needs, as indicated in the medical records, and report any concerns to the appropriate manager.

The statements contained herein describe the scope of the responsibility and essential functions of this position but should not be considered to be an all-inclusive listing of work requirements. Individuals may perform other duties as assigned including work in other areas to cover absences or relief to equalize peak work periods or otherwise balance the workload. 

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES: 

1. High school diploma or equivalent  
2. General knowledge of computers  
3. Proficient in the English Language  
4. Previous experience in Medical Records or Behavioral Health preferred

PHYSICAL DEMANDS: 

1. Remaining stationery, such as standing or sitting, for prolonged periods. 
2. Ability to focus on computer screens for extended periods of time. 
3. Frequently moving from one worksite to another to accomplish tasks. 
4. Adjusting or moving objects up to 25 pounds in any direction. 
5. Repeating motions that may include the wrists, hands or fingers. 
6. Communicating with others to exchange information. 

WORKING ENVIRONMENT: The environment is a typical office environment. While on location, work is generally performed indoors with ambient room temperatures, lighting, and traditional office equipment. This position may require travel to multiple office locations within the catchment area. 

CONFIDENTIALITY: All Kanza MHGC employees are expected to maintain the highest level of confidentiality and function within the highest ethical standards by exhibiting exemplary conduct. 

SALARY RANGE FOR THIS POSITION: Salary commensurate with experience and Kanza MHGC salary structure.