Medical Record Specialist

Cantex Continuing Care Network•Stafford, TX

20h•Onsite

About The Position

The Medical Records Specialist maintains, audits, and manages hospice medical records and clinical documentation to support accurate, complete, and compliant patient records. This role oversees health information management processes, electronic health record (EHR) documentation, record retention, and documentation quality review activities. The Medical Records Specialist works closely with clinical teams and physicians to support documentation compliance, regulatory requirements, and operational efficiency while safeguarding patient confidentiality and data integrity.

Requirements

High school diploma required
Two (2) to three (3) years of experience in medical records management, health information management, or clinical documentation within hospice or home health.
Strong working knowledge of electronic health record (EHR) systems, medical terminology, and Medicare hospice documentation requirements.
Exceptional attention to detail and commitment to data integrity.
Thorough understanding of HIPAA requirements and medical record confidentiality regulations

Nice To Haves

Associate’s degree or certification as a Registered Health Information Technician (RHIT) preferred.

Responsibilities

Review clinical charts, physician orders, and face-to-face encounter documentation for completeness, required signatures, and compliance requirements.
Manage electronic health record (EHR) systems, including record indexing, filing, organization, retention, and archiving activities.
Coordinate medical record audits and documentation reviews with clinical leadership to identify compliance concerns and documentation gaps.
Follow up with physicians and interdisciplinary team members to obtain missing signatures, documentation, certifications, and required records.
Process authorized requests for medical records in accordance with applicable policies, privacy requirements, and record release procedures.
Monitor, track, and report documentation deficiencies and compliance trends to operational leadership.
Support health information management processes that promote accurate clinical documentation, regulatory compliance, and medical record integrity.
Maintain confidentiality of patient information and ensure compliance with HIPAA and other applicable medical record standards.
Perform other duties and responsibilities as assigned.