Medical Records Specialist

Job Description

Job Description

The Medical Records Specialist maintains the accuracy, integrity, and confidentiality of patient health information across IBHS, in both the electronic health record (EHR) and any remaining paper records. This position indexes and files clinical documentation, processes release of information (ROI) requests, monitors EHR document work queues, and supports providers and staff in the timely, compliant handling of protected health information (PHI). The Medical Records Specialist report to the Clinic Manager.

Schedule:

5 days per week, 8 hours per day

Monday - Friday (with a rotating Saturday)

Shifts:

8:00 – 5:00 PM, 9:00 – 6:00 PM, and 10:00 – 7:00 PM

Locations:

San Bernardino and Banning, CA

ESSENTIAL DUTIES AND RESPONSIBILITIES

Typical responsibilities and duties for the Medical Records Specialist include, but are not limited to:

• Indexes, scans, and files incoming clinical documentation into the correct patient chart in the EHR (eClinicalWorks; Epic upon transition), verifying that documentation is reviewed and signed by the appropriate provider before it is filed.
• Monitors EHR document work queues, inbound fax queues, and unindexed-document folders; routes and files items promptly to keep charts complete and current.
• Processes Release of Information (ROI) requests in accordance with IBHS policy, HIPAA, and the California Confidentiality of Medical Information Act (CMIA): verifies valid authorizations, prepares and transmits records to authorized requestors, and logs disclosures.
• Prepares and transmits obstetric records to the delivering hospital per policy. When a signed Authorization for Release of Information is on file, sends the prenatal history and all pertinent laboratory and supporting data during the first week of the month prior to the expected date of delivery.
• Retrieves and prepares records requested for billing, medical, dental, behavioral health, care coordination, audits, and legal or regulatory requests.
• Reviews charts and encounters for documentation completeness and required provider signatures; follows up on missing or unsigned documentation.
• Maintains records retention and destruction in accordance with the approved retention policy and applicable federal and California law.
• Maintains any remaining paper charts during the EHR transition, including accurate check-out/check-in tracking, and supports scanning and back-file conversion efforts.
• Safeguards PHI at all times and maintains strict confidentiality consistent with HIPAA and IBHS policy.
• Keeps the medical records work area organized, secure, and audit-ready.
• Performs other duties as assigned.

Minimum Qualifications

• High school diploma or equivalent required.
• Prior clerical experience required; experience in medical records or health information in a healthcare setting preferred.
• Experience working within an EHR preferred (eClinicalWorks and/or Epic).
• Ability to file and index numerically and alphabetically with a high degree of accuracy.
• Working knowledge of HIPAA and patient confidentiality requirements, with the ability to safeguard PHI.
• Computer proficiency, including data entry and typing with speed and accuracy.
• Strong attention to detail and precision.
• Ability to work independently, follow directions, and prioritize in a fast-paced, sometimes high-volume environment.
• Effective verbal and written communication with patients, providers, and staff.

Preferred Skills

• Bilingual (English/Spanish).
• Familiarity with ROI processes and medical records retention requirements.
• Coursework toward or completion of a Health Information credential (e.g., RHIT).

Physical Demands & Work Environment

• Work is performed on-site in a clinic/office environment.
• Must be able to work under sometimes stressful conditions arising from the need to multi-task in a fast-paced environment.
• Must be able to lift up to 40 lbs. and push up to 100 lbs. on wheels.
• Must be able to hear and speak clearly in order to communicate with patients and staff both in person and by phone.
• Must have vision, with or without correction, adequate to read documents and a computer screen.
• Must have high manual dexterity and be able to reach above shoulder level, bend, squat, sit, stand, stoop, crouch, reach, kneel, and twist/turn.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act (ADA).

Equal Employment Opportunity

Inland Behavioral and Health Services, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status, or any other characteristic protected by applicable law.

Universal Requirements:

Pre-employment requirements include I-9, positive background and reference check results, complete application, new hire orientation, drug screening and completion of employee health screening.

If you are passionate about supporting community health initiatives through meticulous data management, we invite you to apply today and become a part of our dedicated team at Inland Behavioral and Health Services.