Specialist-Medical Records (Live Oak) #27412, 641

Posted on 04.02.2013
Title: Medical Records Specialist

This is a clerical job of moderate variety and complexity. Specialists perform duties revolving around the maintenance of the Center’s medical records and the coordination of the medical records office functions. Work is performed under the supervision of the Medical Records Director.


1. Maintain all daily office functions in Department/facility

2. File documents in client charts and file client charts when returned.

3. Retrieve and prepare client charts for review or use by clinical/medical staff as needed or requested.

4. Check client charts for accuracy and completeness

5. Enter data from client information forms and chart review forms into Profiler when applicable.

6. Assist on-site and telephone customers with requests for information or service

7. Ensure the confidentiality and security of records

8. Convert large medical records to multiple volumes, when necessary

9. Assemble process and distribute intake packets and records for CSU & Detox clients.

10. Assist Medical Records Director with training of medical records personnel on procedures, protocols, computer/software, etc.

11. Assist the Medical Records Coordinator or Area Director in special projects or assignments as needed.

Graduation from a standard high school or its equivalent and two years of clerical, secretarial, record keeping, or medical records experience. Six months to a one years experience in the health care field. Enrollment in an accredited Health Information Management program may substitute for experience.

Specific competencies required are identified on a department/program specific basis and identified in each employee’s Competency Checklist. Knowledge of HIPAA and State and Federal retention laws governing Substance and Mental Health. Knowledge of and ability to operate computer and or scanning equipment. The following are general and apply to all positions with this title.

Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.

Ability to add and subtract two digit numbers and to multiply and divide with 10's and 100's. Ability to perform these operations using units of American money and weight measurement, volume, and distance.

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.

While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel; reach with hands and arms; and stoop, kneel, crouch, or crawl. The employee is occasionally required to stand, walk, sit, and talk or hear. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, color vision, and ability to adjust focus.

The noise level in the work environment is usually moderate.