Medical Records Specialist

Introduction

Make a Difference with DHSS
Our mission at the Department of Health and Social Services (DHSS) is to improve the quality of life of Delaware citizens by promoting health and well-being, fostering self-sufficiency, and protecting vulnerable populations. We prioritize personal and family independence by assisting individuals and families in a variety of life areas.
We offer numerous career opportunities and are dedicated to attracting and retaining highly talented individuals who are ready to make a difference in their community today. DHSS is a great place to kick-start your profession.
For more information, please visit https://dhss.delaware.gov/dhss/ today!

The Medical Records Specialist works independently with general supervision to coordinate and maintain accurate medical records while ensuring compliance with privacy, security, and regulatory requirements. Reviews and updates patient information, resolves record discrepancies, and notifies supervision of recurring errors. Manages record retention and prepares records for preservation, storage, or disposal in accordance with legal requirements. Supports office operations, assists with audits, and uses electronic health record systems to maintain data integrity.

Collaborates with healthcare staff, agencies, insurers, and clients to ensure accurate and timely information.

Essential functions are fundamental, core functions common to all positions in the class series and are not intended to be an exhaustive list of all job duties for any one position in the class. Since class specifications are descriptive and not restrictive, employees can complete job duties of a similar kind not specifically listed.

• Coordinates and maintains medical records, including physical, electronic, and digital files, documentation, and reports.
• Applies and ensures compliance with best practices, and applicable state and federal laws, rules, and regulations, including procedures on security, patient confidentiality, and authorized user access of medical records.
• Reviews and evaluates patient data, medical history, exam/test results, treatment or services provided, billing, and other information to ensure completeness and accuracy. Resolves discrepancies, deficiencies in information, or other issues.
• Codes and records diagnoses of diseases, operations, illnesses and special therapies in accordance with the specific nomenclative and classification system.
• Transcribes medical dictation.
• Opens, maintains, and closes records; scans, uploads, logs, indexes, and files pertinent documents and information.
• Creates and maintains a variety of record-keeping systems or logs to file, track, and retrieve documents or other information.
• Receives and transfers medical records and reports and responds to requests to release medical information, ensuring the request is valid and authorized.
• Coordinates and schedules services such as patient or client testing, treatment, referrals, appointments, admission, or discharge.
• Uses automated information systems and computer software, including medical classification and categorization software, to enter, update, modify, delete, retrieve, and report on data.
• Performs office support activities such as preparing and distributing correspondence, billing, payment, or other documents; or creating, maintaining, updating, and merging documents or data.
• Prepares records for preservation, storage, or disposal in accordance with legal and related requirements.
• Performs other related duties as required.

• One year of experience in record keeping such as maintaining, filing, tracking, and retrieving physical, electronic, and digital documents, reports, or other information.
• One year of experience in document processing such as reviewing and evaluating records for completeness and conformity with laws, rules, regulations, standards, policies, and procedures, resolving deficiencies, and tracking and monitoring activities.
• One year of experience in using an automated information system to enter, update, modify, delete, retrieve/inquire, and report on data.
• Coursework, training and/or work experience in medical terminology.
• Possession of an Associate’s degree or higher.

• Criminal background check: A satisfactory criminal background check is required as a condition of hire. The recruiting agency may require the applicant to pay for the criminal background check as part of the conditional offer of hire.
• Pre-employment Drug…