Medical Records Specialist, Medical Records (AFSCME)

Job Description

Electronic processing of confidential patient records. Records are prepped, scanned and indexed into the Document Imaging System in an accurate and timely manner. All records are reviewed for deficiencies as well as accuracy. Our goal is to provide complete and timely use of patient data and information for continuity of care as well as reimbursement of services.

Strict confidentiality, security and integrity of all patient data and information is maintained.

Responsibilities may vary based on job role within the department.


Collects and reconciles discharged patient records from Inpatient units and Same Day Surgery. Collects outpatient records from clinical areas and other designated locations. Prepares documents for imaging according to established procedures. Sorts documents according to established prepping procedures. Converts and manages electronic images using electronic scanning technology. Operates scanners to produce high quality electronic images of documents. Uploads images electronically into the Imaging system, upon satisfactory completion of quality review. Conducts qualitative image review for consistency in: Patient name, medical record number, account/ CSN number, date of service, document type and document clarity and legibility. Determines if there are any imaging problems and reconcile any inaccurate indexing information. References clinical information to determine the appropriate document type when bar code is absent. Ensures proper organization and maintenance of the medical record in all media. Consistently meets department productivity and quality standards. Ensures accurate, complete electronic records are available for continuity of care and for legal and reimbursement purposes. Maintains a neat functional work space that is organized, safe, accessible, and that provides an effective and efficient environment for employees, patients, and families. Ability to scan and index batches and prep all charts and documents batches for scanning to the appropriate queues according to department policy and procedure at least 98% of the time.(98% or above - Does Well; 97% or below - Needs Improvement). Ability to accurately analyze or rework electronic records according to Joint Commission requirements and Medical Staff Bylaws and Rules and Regulations, correctly identifying missing elements and assigning deficiencies to the correct physician at least 97% of the time. Ability to verify physician dictations and provide frontline communication with medical staff to assistance with completion of chart deficiencies. (97% or above - Does Well; 96% or below - Needs Improvement). Ability to perform manual document indexing to include correctly inserting, splitting, moving and appending pages/documents when and where appropriate at least 98% of the time. Ability to index to the correct patient, account and document types. (98% or above - Does Well; 97% or below - Needs Improvement). Ability to meet productivity and quality standards according to department policy and procedure for each job function assigned on a weekly basis. (Meets standards - does well; Below standards - needs improvement. Ability to use high-speed scanning equipment or flatbed scanners effectively with the ability to do basic trouble-shooting as necessary on equipment and report efficiently to the Helpdesk any system or equipment issues. Effectively demonstrates skills related to operating office equipment. Performs equipment checks on cameras, rollers, image guides, etc. to verify the system is operational at the beginning of each shift. Performs first level of troubleshooting as a response to failure of technical equipment, engaging additional resources as appropriate. Responsible for the confidentiality and security of all patient health records for the hospital. Understands all rules and regulations regarding the proper release of patient information. Provides assistance to other UCMC staff members and customers by: Processing requests for patient information in a manner that adheres to HIPAA and HIM department standards, prioritizing requests for information, and troubleshooting issues. Assists with the appropriate release of patient information, upon request, according to UCMC and department policies. Demonstrates flexibility in work assignments such that needs of all customers are met. Functions as an effective team member within individual teams and departmental teams.


Minimum Required: High School Diploma or GED, Academic / College Preparatory. | None Required, however, Associate Degree/Registered Health Information Technician (RHIT) Preferred, RHIT eligible. | Minimum Required: 2 years Preferred: In a HIM/Healthcare area.