Job Purpose:

The Medical Records Specialist/Medical Scribe area of responsibility is to establish and maintain a highly professional, with detailed accuracy and efficient medical records department, providing an effective service for both clinical and non-clinical team members.  The role will involve working within established quality standards, protocols, and best practice specified by policy, payers and legislation.  In addition, he/she will assist our healthcare team with patient medical record documentation, ensuring clear, concise, accurate details are captured in a timely fashion.  The Medical Records Specialist/Medical Scribe is also responsible for representing the organization professionally, with the highest level of quality customer service to patients, all team members, as well as a variety of external customers.  In addition, he/she will effectively manage the volume of work without allowing quality to be comprised; and, will partake in ad hoc project work as requested by local physicians and/or management.

Essential Functions:

• Compiles, verifies, and files medical records.
• Transcribe patient appointments w/accuracy.
• Reviews medical records for completeness, assembles records into standard order, and files records in designated areas or electronic medical records system.
• Facilitates diagnostic tests and referrals to specialists.
• Assists provider with coordination of fundamental patient care.
• Files processed labs, pathology reports and loose correspondence into patient records once physician has reviewed and signed appropriately.
• Responds to requests for information from providers, team members, etc.
• Files & ensures accuracy according to established policies and procedures.
• Operates computer with efficiency to retrieve data and file signed correspondence and reports.
• Combines and/or assist to combine duplicate patient records submitted from patient accounts department.
• Maintains filing system by organizing patient records to ensure records are readily accessible by all departments.
• Answers calls / requests from clinical staff pertaining to patient visits, medical records, etc.
• Completes, mails, scans, faxes, and files physician’s transcription documentation after quality control conducted for completeness and accuracy.
• Comply with federal HIPAA regulations and practice policies for the privacy and security of patient information; explain the law and company privacy policy to patients as needed, reiterate to team members; maintain appropriate documentation of access to all medical records.
• Selects, coordinates, pulls, and processes files for year-end purging.
• Maintains a clean, organized and professional working environment.
• Regular attendance and punctuality.
• Contributes to team effort by accomplishing related results as needed.
• Ensures that all processing and reporting deadlines are consistently achieved and helps other team members to do so as well.
• Perform any other functions as required by management.

Qualifications and Education Requirements

• Bachelor’s degree in healthcare field desired.
• Successful completion of Medical Assistant training program is an asset.
• Proficient experience with medical terminology
• Impeccable verbal, written and interpersonal skills
• Ability to work a flexible schedule as necessary
• Strong attention to detail
• Excellent computer skills; basic Microsoft Office skills a must.

Preferred Skills                              

• Excellent bedside manner
• Prior experience with Electronic Medical Records system

Required Competencies

Excellent judgment, dependability, conscientious performance.  Detail oriented.  Exceptional interpersonal and communication skills.  Caring and empathetic.  High ethical/moral standards. Mechanical ability and manual dexterity for operating complicated equipment and/or multi-tasking.

Physical Demands and Work Environment

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical demands:  While performing the duties of this job, employee is required to walk; sit; use hands to handle, or feel objects, tools, or controls; reach hands and arms; talk and hear.  Employee must lift and/or move 50 pounds.  Specific vision abilities required by the job include close vision, distant vision, color vision, peripheral vision, depth perception, speech clarity, climb, balance, and stoop, kneel, and bend.

Work environment: While performing the duties of this job, the employee is exposed to environmental risk of radiation exposure, and biohazard exposure.