medical records manager

ClearSky Health

Our hospital provides high-quality care that transforms the lives of those living with disabling injuries and illnesses. We distinguish ourselves through our commitment to excellence, to our patients, to our employees, and to the communities we serve. The HIM Manager is responsible for maintaining the security, confidentiality, completeness, and accuracy of medical records in accordance with policies and procedures and within the guidelines of regulatory agencies. The HIM Manager may also act as Privacy Officer for the Hospital. Oversees compliance efforts related to the Centers for Medicare &amp; Medicaid Services (CMS) Review Choice Demonstration (RCD) and the Final Rule Audit (FRA). Serves as the primary onsite contact for all RCD/FRA compliance initiatives. This position must integrate company values into daily practice. Essential Functions: Directs, plans, schedules, and participates in day-to-day activities within HIM department, including , indexing, transcription, quantitative analysis, chart completion, the release of medical record information and abstracting of medical information. Oversee daily concurrent medical record completion, collaborating across all disciplines to ensure 100% accuracy and adherence to the Final Rule. Acts as Cerner superuser and source expert in auditing Final Rule elements. Supports providers using Cerner. Directs record assembly and reviews medical records for data elements required for chart completion. Monitors and evaluate physicians and hospital staff to ensure compliance with record keeping requirements. Oversees all ongoing activities related to the development, implementation, maintenance of, and adherence to the organization&rsquo;s policies and procedures covering the privacy of, and access to, patient health information in compliance with federal and state laws and the healthcare organization&rsquo;s information privacy practices. Monitors and evaluates physicians and hospital staff to ensure compliance with record keeping requirements. Collaborates with RCD Leadership and hospital staff on process improvement and education regarding documentation and timeliness. Provides development guidance and assists in the identification, implementation, and maintenance of organization information privacy policies and procedures in coordination with Hospital administration, Corporate Compliance Officer, and legal counsel. May perform initial and ongoing credentialing for Hospital medical staff. Safeguards the confidentiality of all medical records by ensuring the Release of Information policy is followed in accordance with HIPAA and other requirements; securing legal/risk management records; responding timely to subpoenas and/or court orders; and representing the hospital in court hearings and/or depositions as required. Provides an environment conducive to safety for patients, visitors, and staff. Assesses the risks for safety and implements appropriate precautions. Complies with appropriate and approved safety and Infection Prevention standards. Completes required trainings, as assigned. Performs other duties as assigned to support overall effectiveness of the organization. Once the HIM&rsquo;s hospital is formally under Review Choice Demonstration, the following will be incorporated into day-to-day duties: Follow established protocols to facilitate Medicare affirmations and respond timely to non-affirmations under the Review Choice Demonstration process. Stay informed about changes in RCD/FRA processes, including regional Medicare Administrative Contractor (MAC) approaches and review outcomes. Communicate reasons for admission non-affirmations/denials with hospital leadership and RCD leadership and assist in providing necessary justifications. Assists as directed with denials through the appeal process. Includes synthesizing clinical documentation for each patient&rsquo;s stay into justification for services for all payors. Manage tracking systems to ensure deadlines are met and real-time data on new admissions is available for timely submissions. Minimum Job Requirements Minimum Education &amp; Experience: Two years medical records experience required Two years of medical coding experience preferred. Degree in Health Information Management or related subject required. Prefer program accredited by CAHIIM (Commission on Accreditation for Health Informatics and Information Management). Experience in a management role preferred. Required Licenses, Certifications, and/or Documentation: RHIA or RHIT certification preferred. CCS preferred as additional credential. Required Knowledge, Skills, and Abilities: Demonstrates knowledge in information privacy laws including 45 CFR, Health Insurance Portability and Accountability Act (HIPAA), and state medical records law. Demonstrates a clear working knowledge of general hospital operations. Knowledge of accreditation standards to ensure adherence to all standards set forth by state and accrediting agencies of TJC and CMS. Demonstrates an understanding of treatment costs and financial support as they relate to quality and efficiency. Working knowledge of medical terminology, abbreviation, and spelling. Ability to maintain exceptional levels of confidentiality. Demonstrates proficiency with general computer skills including data entry, word processing, email, and records management. Demonstrates critical thinking skills. Ability to prioritize, meet deadlines, and complete complex tasks. Ability to maintain quality and safety standards. Ability to work closely and professionally with others at all levels of the organization. Effective organizational and time management skills. Physical Requirements Over the Course of a Shift: A significant amount of sitting, walking, bending, reaching, lifting, and carrying, often for prolonged periods of time. Lifting/exerting of up to 10 lbs. Sufficient manual dexterity to operate equipment and computer keyboard. Close vision and the ability to adjust focus. Ability to hear overhead pages.

Health Information Manager (HIM) - Based in Lake City, FL Occasional travel to Lecanto, FL

Softview Infotech

Position: Medical Records OfficerExperience: 2+ YearsLocation: MaduraiJob Summary:We are seeking a detail-oriented and organized Medical Records Officerto manage, maintain, and safeguard patient medical records in our multi-speciality hospital. The ideal candidate will ensure accuracy, confidentiality, and systematic record handling while supporting smooth hospital operations and compliance standards.Key Responsibilities:<ul><li>Maintain and organize inpatient and outpatient medical records accurately</li><li>Ensure proper documentation of patient files, reports, discharge summaries, and consent forms</li><li>Retrieve and provide medical records as requested by authorized personnel</li><li>Maintain confidentiality and comply with hospital policies and legal regulations</li><li>Coordinate with doctors, nursing staff, and billing department for record completion</li><li>Digitize records and update Hospital Management System (HMS) regularly</li><li>Prepare reports related to patient records and documentation audits</li><li>Archive and store records systematically for easy retrieval</li><li>Ensure compliance with NABH and other healthcare regulatory standards</li></ul>Required Skills &amp; Competencies:<ul><li>Strong attention to detail and documentation skills</li><li>Knowledge of medical terminology and hospital documentation processes</li><li>Familiarity with Hospital Management Systems (HMS)</li><li>Basic computer proficiency (MS Office, Excel, data entry)</li><li>Good communication and coordination skills</li><li>Ability to handle confidential information responsibly</li></ul>Qualification:<ul><li>Any Graduate (Healthcare Administration preferred)</li><li>Diploma / Certification in Medical Records Management (added advantage)</li></ul>Why Join Us?<ul><li>Work in a reputed multi-speciality hospital</li><li>Professional growth in healthcare administration</li><li>Supportive and collaborative work environment</li><li>Competitive salary and benefits</li></ul>Job Types: Full-time, PermanentPay: ₹216,000.00 - ₹240,000.00 per yearBenefits:<ul><li>Provident Fund</li></ul>Application Question(s):<ul><li>Mention the notice period in days. </li></ul>Experience:<ul><li>Medical records: 2 years (Required)</li></ul>Work Location: In person

Medical Records Officer

Northwest Florida Physicians Group

Overview Join our dynamic healthcare team as a Medical Records Clerk, where your organizational skills and attention to detail will play a vital role in maintaining accurate and confidential patient records. In this energetic role, you will ensure seamless management of medical documentation, support healthcare providers with timely access to records, and uphold the highest standards of data integrity. Your proactive approach will contribute to delivering exceptional patient care and operational efficiency within our medical facility.Duties<ul><li>Organize, file, and maintain comprehensive medical records in accordance with privacy regulations and organizational policies</li><li>Retrieve and distribute patient files efficiently to authorized personnel, ensuring quick access when needed</li><li>Update patient information accurately within Electronic Health Record (EHR) systems, including demographics, medical history, and treatment notes</li><li>Scan, digitize, and archive paper-based documents into secure electronic formats using EHR platforms</li><li>Verify the completeness and accuracy of medical records before filing or sharing with healthcare providers</li><li>Assist with data entry tasks related to patient visits, test results, and billing information to support clinical operations</li><li>Ensure compliance with confidentiality standards and legal requirements governing medical records management</li></ul>Experience<ul><li>Prior experience working in a medical office or healthcare environment is highly preferred</li><li>Familiarity with Electronic Health Record (EHR) systems and digital recordkeeping processes</li><li>Strong understanding of medical terminology to accurately interpret and organize health information</li><li>Proven ability to handle sensitive information with discretion and maintain strict confidentiality</li><li>Excellent organizational skills with meticulous attention to detail for record accuracy and completeness</li><li>Ability to prioritize tasks efficiently in a fast-paced environment while adhering to deadlines</li></ul>This position offers an engaging opportunity for motivated individuals eager to contribute to quality healthcare delivery through precise record management. If you thrive in organized settings and are passionate about supporting healthcare teams, we invite you to apply!Pay: $16.50 - $17.50 per hourBenefits:<ul><li>401(k) matching</li><li>Paid time off</li></ul>Work Location: In person

Medical Records Clerk

THE OXFORD MEDICAL COLLEGE & HOSPITAL

1. Planning, organizing and coordinating Inter and Intradepartmental tasks.2. Supervision of day to day activities of MRD.3. Pre-assemble all patients&rsquo; medical records and deliver to providers on time.4. Management of court cases relating to medical records.5. Complying with statutory compliance.6. Preparing duty rosters and allocating work to personnel working in MRD.7. Identification and acquisition of resources for MRD department.8. Updating the technology as per the strategic changes in the organization and the legal and other regulatory requirements.9. Generation of reports and contributing to various other data base, both internal and external as per the requirements and agreed policy.10. Accepting and verifying the request of various parties and agencies for retrieval of data and patient records.11. Day to day administration and trouble-shooting as and when required.12. Responding to all agencies, groups and individuals who interact with the MRD department.13. To Ensure ICD 10 coding for every patient&rsquo;s diagnosis at the IPD level for all patients Files.14. To maintain and improve Quality of MRD services by:&middot; Color Coding of Medical Record Files&middot; Following SOPs that have been laid down by Hospital.&middot; Actively participation in meetings.15. Participating in quality improvement activities including audits, development and implementation of protocols, accreditation requirements etc.16. To take part in all department meetings.17. Ensure Daily Audit Work of Active File and Medical Record Files18. To maintain privacy &amp; confidentiality of the patient records.19. To keep the medical records in the safe custody &amp; complete all the time.20. To make the records available as and when required.21. To interact &amp; ensure with other locations for procuring necessary records.22. To check the records for accuracy &amp; completion within defined time-scales.23. To file records systematically with the standard indexing practice.24. To follow up with the physicians/ nurses for Medical Record completion on priority.25. To communicate with the government departments/ officials for medico legal requirement on an ongoing need basis.26. To assist in generation of data and reports as per requirements of the system.27. To Ensure Submission of Daily/ weekly/Monthly Reports for all government departments/ Agencies for official purpose and list of department and agencies are given below along with Periodicity of data submission:&middot; The notifiable diseases which are notified to CMO Office &amp; Nagar Nigam office on monthly basis.&middot; Birth registration is being done by filling and sending a death report on the approved form to the Birth Registration, Nagar Nigam.&middot; Death registration is being done by filling and sending a death report on the approved form to the Birth &amp; Death Registration, Nagar Nigam.28. Ensure Monthly Report of Some Quality Indicators which are Defined by NABH:Job Type: Full-timePay: From ₹45,000.00 per monthBenefits:<ul><li>Health insurance</li></ul>Work Location: In person

medical record officer

Mirage Post Acute

<div>General Purpose
The primary purpose of your job position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines as well as in accordance with our facility&rsquo;s established privacy policies and procedures.
Essential Duties
Administrative Functions<ul><li>Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.</li><li>Assist in organizing, planning and directing the medical records department in accordance with established policies and procedures.</li><li>Assist the Medical Records/Health Information Consultant as required.</li><li>Maintain minutes of meetings. File as necessary.</li><li>Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.</li><li>Assist in recording all incidents/accidents. File in accordance with established policies and procedures.</li><li>Retrieve resident records (manually/electronically). Deliver as necessary.</li><li>Files information such as nurses&rsquo; notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.</li><li>Collect, assemble, check and file resident charts as required.</li><li>Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.</li><li>Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.</li><li>Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.</li><li>Establish a procedure to ensure resident charts/records do not leave the medical records room except as authorized in our policies and procedures.</li><li>Maintain a record of authorized information released from charts/records, i.e., type information, name of recipient, date, department, etc.</li><li>Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc. in accordance with current Privacy Rules.</li><li>Index medical records as directed by the medical records/health information consultant.</li><li>Maintain various registries as directed including register for admission and discharge of residents.</li><li>Transcribe and type reports for physicians as necessary.</li><li>Collect charts, assemble them in proper order, and inspect them for completion.</li><li>Pick up and deliver resident medical records from wards, nurses&rsquo; stations, and other designated areas as necessary.</li><li>Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.</li><li>Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.</li><li>Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.)</li><li>Assure that medical records taken from the department are signed out and signed in upon return to the department.</li><li>File active and inactive records in accordance with established policies.</li><li>Index medical records as directed.</li><li>Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.</li><li>Agree not to disclose resident&rsquo;s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.</li><li>Report any known or suspected unauthorized attempt to access facility&rsquo;s information system.</li><li>Assume the administrative authority, responsibility, and accountability of performing the assigned duties of this position.</li></ul>
Committee Functions<ul><li>Perform secretarial duties for committees of the facility as directed.</li><li>Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.</li></ul>
Personnel Functions<ul><li>Report known or suspected incidents of fraud to the Administrator.</li><li>Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines.</li></ul>
Staff Development<ul><li>Attend and participate in mandatory facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, etc.).</li><li>Attend and participate in workshops, seminars, etc., as approved.</li></ul>
Safety and Sanitation<ul><li>Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately.</li></ul>
Equipment and Supply Functions<ul><li>Report equipment malfunctions or breakdowns to your supervisor as soon as possible.</li><li>Ensure supplies have been replenished in work areas as necessary.</li><li>Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of workday, etc.</li></ul>
Budget and Planning Functions<ul><li>Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.</li></ul>
Other duties as assigned.
Supervisory Requirements
You are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.
Qualification
Education and/or Experience
Must possess, as a minimum, a high school diploma or GED. Must be able to type a minimum of 45 words per minute and use dictation equipment. A working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required. On-the-job training provided in medical record and health information system procedures. Must be knowledgeable of medical terminology. Be knowledgeable in computers, data retrieval, input and output functions, etc.
Language Skills
Must be able to read, write, speak, and understand the English language. Ability to read technical procedures.
Mathematical Skills
Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.
Reasoning Ability
Must possess the ability to make independent decisions when circumstances warrant such action. Must possess the ability to deal tactfully with personnel, residents, visitors and the general public. Must possess the ability to work harmoniously with other personnel. Must possess the ability to minimize waste of supplies, misuse of equipment, etc. Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices. Be able to follow written and oral instructions. Must not pose a direct threat to the health or safety of other individuals in the workplace.
Physical Demands
Must be able to move intermittently throughout the workday. Must be able to speak and write the English language in an understandable manner. Must be able to cope with the mental and emotional stress of the position. Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met. Must function independently, have personal integrity, have flexibility, and the ability to work effectively with other personnel. Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination. Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet. May be necessary to assist in the evacuation of residents during emergency situations.
Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Works in office areas as well as throughout the facility. Moves intermittently during working hours. Is subject to frequent interruptions. Works beyond normal working hours, weekends and holidays and on other shifts/positions as necessary. Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.). Attends and participates in continuing educational programs. Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants. Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses. Communicates with nursing personnel, and other department personnel. Is subject to hostile and emotionally upset residents, family members, personnel, visitors, etc. Is involved with residents, family members, personnel, visitors, government agencies and personnel, etc., under all conditions and circumstances. May be subject to the handling of and exposure to hazardous chemicals.
Additional Information
Note: Nothing in this job specification restricts management&rsquo;s right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described under various headings above. They may be subject to change at any time due to reasonable accommodation or other reasons.
The above statements are strictly intended to describe the general nature and level of the work being performed. They are not intended to be construed as a complete list of all responsibilities, duties, and skills required of employees in this position.</div>

Medical Records Assistant-Full Time

Oak Knoll Health and Rehabilitation LLC

<div>Oak Knoll Health and Rehabilitation, were we combine high-quality, person-centered care with a professional environment built on teamwork, accountability, and pride in the difference we make every day. 
Be the Backbone of Clinical Excellence &mdash; LPN Medical Records Nurse
Oak Knoll Health and Rehabilitation is seeking a detail-driven LPN Medical Records Nurse to join our team.<h2 class="jobSectionHeader"> 
Position Overview:</h2>
The LPN Medical Records Nurse plays a key role in maintaining complete, accurate, and compliant clinical records. This position works closely with nursing leadership and interdisciplinary teams to ensure documentation integrity, and regulatory compliance, upon admission, maintenance of record and record closure at discharge.<h2 class="jobSectionHeader"> 
Key Responsibilities:</h2><ul><li>
Maintain and organize resident medical records (electronic and/or paper)</li><li>
Audit charts for completeness, accuracy, and compliance</li><li>
Monitor physician orders and ensure proper documentation</li><li>
Prepare records for admissions, discharges, and transfers</li><li>
Support survey preparation and regulatory standards</li><li>
Collaborate with nursing staff to resolve documentation discrepancies</li><li>
Ensure strict confidentiality in accordance with HIPAA</li></ul><h2 class="jobSectionHeader"> 
Qualifications:</h2><ul><li>
Active LPN license in good standing</li><li>
Long-term care experience preferred</li><li>
Strong understanding of documentation and regulatory standards</li><li>
Highly organized with strong attention to detail</li><li>
Experience with EMR systems</li><li>
Ability to work independently while supporting the clinical team</li></ul><h2 class="jobSectionHeader"> 
Benefits:</h2><ul><li>
Competitive wages for Licensed Practical Nurses (LPNs)</li><li>
Blue Cross Blue Shield Health and Dental Insurance</li><li>
Vision Insurance
</li><li>Life insurance</li><li>
Paid Time Off (PTO) and Paid Holidays
</li><li>401(k) Retirement Savings Plan with Company Match</li></ul> 
If you&rsquo;re ready to bring organization, accountability, and clinical excellence together, we&rsquo;d love to meet you! 
We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. 
&quot;Our Family Caring For Yours&quot;</div>

Medical Records Nurse - LPN

Mukat Hospital + Heart Institute - Super Speciality Hospital

The MRD In-Charge is responsible for managing, maintaining, and securing all patient medical records in compliance with hospital policies and regulatory requirements. The role ensures timely documentation, retrieval, and confidentiality of patient information to support patient care, research, legal, and administrative functions.Key Responsibilities:<ul><li>Supervise and coordinate all activities of the Medical Records Department.</li><li>Ensure accurate registration, filing, indexing, and maintenance of inpatient and outpatient medical records.</li><li>Oversee the timely completion and discharge summary of patient files.</li><li>Maintain confidentiality and security of all medical records in accordance with hospital policy and legal standards.</li><li>Monitor proper coding and indexing of diseases, procedures, and treatments as per ICD classification.</li><li>Ensure records are available for audits, medico-legal cases, insurance claims, and internal review.</li><li>Coordinate with doctors and nursing staff for timely completion of patient files.</li><li>Implement and maintain an efficient medical record management system (manual and electronic).</li><li>Prepare statistical reports and data analysis related to patient admissions, discharges, and mortality.</li><li>Ensure compliance with NABH, ISO, and other accreditation documentation requirements.</li><li>Train and supervise MRD staff for record handling, documentation, and data confidentiality.</li><li>Liaise with IT and quality departments for EMR (Electronic Medical Records) updates and improvements.</li><li>Handle medico-legal case (MLC) documentation and ensure proper record submission to authorities.</li><li>Conduct regular audits of medical records for accuracy and completeness.</li></ul>Job Types: Full-time, PermanentWork Location: In person

MRD In-charge

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