Medical Records Specialist

STERLING CARE BETHESDA

Job Description – Medical Records Specialist

Department: Medical Records / Health Information Management
Position Title: Medical Records Specialist
Classification: Non-Exempt
Employment Status: Full-Time
Reports To: Executive Director / Director of Nursing
Location: Bethesda, Maryland

Position Summary

The Medical Records Specialist is responsible for maintaining accurate, complete, organized, and confidential medical records for all residents in accordance with federal and state regulations, HIPAA requirements, and facility policies and procedures.

This position plays a critical role in ensuring the integrity of resident health information, supporting clinical operations, maintaining regulatory compliance, and preparing medical records for audits, inspections, and surveys.

Essential Duties and Responsibilities

1. Medical Records Management

• Maintain accurate, complete, and up-to-date medical records for all residents.

• Organize, file, scan, and retrieve medical documentation in accordance with facility procedures.

• Review admission, discharge, and transfer records for completeness and accuracy.

• Ensure physician orders, progress notes, assessments, and other required documentation are properly maintained.

• Monitor medical records for missing documentation and follow up with appropriate clinical personnel.

• Maintain archived medical records in accordance with applicable retention requirements.

2. Regulatory Compliance and Confidentiality

• Ensure medical records comply with HIPAA, CMS, Maryland regulations, and facility policies.

• Protect confidential resident information from unauthorized access, use, or disclosure.

• Process authorized requests for medical records in accordance with applicable privacy laws.

• Assist with preparation for state surveys, regulatory inspections, and internal audits.

• Maintain appropriate documentation to demonstrate compliance with medical records requirements.

3. Documentation Audits and Quality Assurance

• Conduct routine audits of resident medical records to identify incomplete or missing documentation.

• Monitor timely completion of physician documentation, discharge summaries, and other required records.

• Prepare reports identifying documentation deficiencies and outstanding items.

• Collaborate with nursing leadership and other departments to resolve documentation concerns.

• Participate in Quality Assurance and Performance Improvement (QAPI) initiatives as assigned.

4. Electronic Health Records

• Maintain resident information within the facility's Electronic Health Record (EHR) system.

• Ensure accurate scanning, uploading, indexing, and filing of electronic documents.

• Identify and report documentation discrepancies or system-related issues.

• Assist authorized staff with locating and retrieving medical records.

• Follow facility procedures for electronic record security and access.

5. Communication and Administrative Support

• Communicate professionally with physicians, nursing staff, department managers, residents, and authorized representatives.

• Respond promptly to authorized medical records requests.

• Coordinate documentation needs with nursing, admissions, social services, and administrative departments.

• Maintain organized tracking logs and reports.

• Attend departmental meetings, mandatory training, and assigned in-service programs.

Minimum Qualifications

Education

• High school diploma or GED required.

• Associate degree in Health Information Management, Healthcare Administration, or a related field preferred.

Experience

• Minimum of one year of medical records or healthcare administrative experience preferred.

• Previous experience in a skilled nursing facility, long-term care facility, or rehabilitation center strongly preferred.

• Experience working with electronic health records preferred.

• Knowledge of HIPAA regulations and medical terminology preferred.

Required Skills and Competencies

• Strong organizational skills and attention to detail.

• Ability to maintain confidentiality and handle sensitive information.

• Knowledge of medical records procedures and documentation standards.

• Proficiency in Microsoft Office and electronic healthcare systems.

• Strong written and verbal communication skills.

• Ability to prioritize assignments and meet deadlines.

• Ability to work independently and collaboratively with clinical leadership.

• Professionalism, dependability, and strong problem-solving skills.

Physical Requirements

• Ability to sit, stand, and walk throughout the workday.

• Ability to operate standard office equipment.

• Ability to lift and move files or office materials up to 20 pounds, with or without reasonable accommodation.

• Ability to perform repetitive computer and clerical tasks.

Performance Expectations

The Medical Records Specialist is expected to:

• Maintain accurate, complete, and confidential resident records.

• Complete assigned medical records audits within established deadlines.

• Identify and promptly report missing or incomplete documentation.

• Support successful regulated is an Equal Opportunity Employer and provides reasonable accommodations in accordance with applicable law. Ory surveys and internal compliance reviews.

• Maintain professional communication with staff, residents, and leadership.

• Demonstrate accountability, reliability, and adherence to facility policies.

Additional Responsibilities

This job description is intended to describe the general nature and level of work performed by employees assigned to this position. It is not intended to be an exhaustive list of all duties and responsibilities. Additional duties may be assigned based on operational needs.