Medical Records Specialist

Position Overview

Maintains medical records in accordance with federal and state guidelines as well as established policies and procedures to assure that a complete medical records program is maintained. Ensures quality, accuracy, accessibility, and security in both paper and electronic systems. Directs, analyzes, researches, and comprehends critical data points to determine missing components of the comprehensive medical record. Provides guidance, support, communication, and coordination of documents with multiple legal, operations, and clinical programs.

Reviews all quality data to ensure accuracy and assist with quality improvement plans.

• Gathers, prints, and collects all responsive pieces of a requested medical record for production to resident, authorized representative, or attorney.
• Works with Clinical Risk Manager to assist with identifying potential compensable events.
• Works with Campuses to ensure incident workflow and soft files are completed as necessary when notified of certain events.
• Utilizes various classification systems to code and categorize patient information for risk and legal reviews.
• Assists in the development of procedures to ensure records are properly stored and copied for production requests.
• Works with Compliance to ensure proper authority to produce requested records.
• Protects the security of medical records to ensure confidentiality is maintained.
• Reviews records for completeness, accuracy, and compliance with regulations.
• Assists with developing and providing training on record documentation and retention.
• Works with Paralegal as needed to assist in obtaining documentation for litigation or claim purposes.
• Assists in identifying and requesting soft file documentation on Events.
• Works as a liaison with Clinical Documentation Specialist to help identify and report areas of opportunities in documentation.
• Participates and identifies strategies for improving legal/risk system practices, and effective system use by users for quality improvement.
• Provides knowledge of care provider systems to create solutions that will impact quality across the care continuum.
• Assists in the development of policies and procedures as necessary to ensure accurate documentation in Matrix Care.
• Utilizes trends, quality data and analyzes to identify issues with retention and production of medical records, as well as other potential litigation campus records.
• Provides education related to maintaining comprehensive medical records.
• Directs automated reporting to provide timely information, allowing decisions to be made in a real‑time environment.
• Uses critical thinking skills to know when to request and communicate on missing documentation essential to a complete record.
• Collaborates with department heads, divisional support, and campus personnel to achieve goals and objectives.
• Other duties as assigned.

• Education:
  
  Bachelor Degree
• Experience:
  
  3-5 years

Yes: 25%

US-KY-Louisville

Trilogy Health Services

303 N. Hurstbourne Parkway

Louisville

KY

• Competitive salaries and weekly pay
• 401(k) Company Match
• Mental Health Support Program
• Student Loan Repayment and Tuition Reimbursement
• Health, vision, dental & life insurance kick in on the first of the month after your start date
• First time home buyers' program
• HSA/FSA
• And so much more!

As one of Fortune's Best Places to Work in Aging Services, a certified Great Place to Work, and one of Glassdoor's Top 100 Best Companies to Work, Trilogy is proud to be an equal opportunity employer committed to helping you reach your full potential and to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy or any other protected characteristic as outlined by federal, state or local laws.

FOR THIS TYPE OF EMPLOYMENT STATE LAW REQUIRES A CRIMINAL RECORD CHECK AS A CONDITION OF EMPLOYMENT.