Job Description

Roles & Responsibilities

• Assemble and organize discharged patient medical records per established procedures.

• Conduct quantitative analysis of inpatient and outpatient records for documentation completeness and compliance.

• Identify chart deficiencies and communicate required corrections to physicians and nursing staff.

• Maintain and monitor incomplete medical record tracking systems.

• Follow up with physicians regarding outstanding documentation deficiencies.

• Manage filing, scanning, retrieval, and archiving of medical records and related reports.

• Supervise the prompt retrieval and delivery of requested medical records.

• Prepare monthly reports on medical record deficiencies and documentation compliance.

• Perform quality control reviews on records awaiting completion.

• Investigate missing, misplaced, or incorrectly filed medical records.

• Verify patient information and maintain accurate record indexing and filing systems.

• Ensure strict confidentiality and security of all patient health information.

• Respond to inquiries related to medical records and departmental procedures.

• Support departmental operations and perform additional duties as assigned.

Desired Candidate Profile

Education

• Relevant bachelor’s degree, Health Information Management, Nursing, or a related healthcare field.

• Medical background is required.

Experience

• Minimum 5 years of experience in a Medical Records Department.

• Previous experience in medical record analysis, assembly, or health information management is preferred.

• Familiarity with JCI standards and healthcare documentation requirements is an advantage.

Skills

• Strong knowledge of medical terminology and healthcare documentation practices.

• Good command of English — written, spoken, and reading.

• Strong attention to detail, organizational skills, and commitment to confidentiality.

• Proficient in medical records systems and electronic documentation processes.

Required Certificates

• Registered Health Information Administrator (RHIA) — preferred.

• Registered Health Information Technician (RHIT) — preferred.

• Coding Certification (Certified Coding Specialist (CCS) or Certified Coding Associate (CCA) —Mandatory.