Medical Records Specialist I

CHARLOTTE BEHAVIORAL HEALTH CARE INC • Punta Gorda, FL

6d • Onsite

About The Position

Maintain, safeguard, and ensure the integrity of all patient health records, including oversight of record accuracy, completeness, confidentiality, auditing processes, and lawful disclosure in accordance with federal, state, and organizational requirements. Ensure all medical records are complete, timely, accurate, and compliant with applicable regulations, including documentation standards, signature requirements, and established timelines (e.g., 24-hour, 48-hour, or business-day requirements as defined by policy and payer expectations). Accurately scan, index, upload, and validate documents within the Electronic Medical Record (EMR), ensuring proper patient matching, document type classification, and image quality to support clinical, legal, and billing functions. Perform reconciliation and maintenance of inactive, discharged, or archived records, including verification of record completeness, closure of outstanding deficiencies, and adherence to retention and purging schedules. Verify and maintain the accuracy of patient demographic, encounter, and provider data within the EMR, ensuring data integrity for clinical care, reporting, billing, and regulatory compliance. Process requests for medical records in strict compliance with HIPAA, 42 CFR Part 2, and applicable state laws, including validation of authorizations, application of the minimum necessary standard, and secure release of information. Maintain detailed and accurate documentation of all disclosures, including completion of disclosure logs and accounting of disclosures as required by regulatory standards. Conduct assigned medical record audits to evaluate documentation quality, completeness, timeliness, and regulatory compliance, and promptly report findings, trends, and deficiencies to the Health Information Supervisor and/or Quality Management. Assist in preparation for and participation in internal and external audits (e.g., CARF, AHCA, DCF, Medicaid, and other regulatory bodies), including gathering documentation, responding to audit requests, and implementing corrective actions as directed. Provide timely, accurate, and professional responses to requests for medical records from staff, patients, and authorized third parties, ensuring compliance with confidentiality requirements and organizational service standards. Assist patients, family members and 3rd parties with accurate completion of the release of information, to include face to face assistance where appropriate.

Requirements

• High school diploma or equivalent.
• Minimum one (1) year experience in health information/medical records required.

Nice To Haves

• Two (2) years of clerical experience preferred.

Responsibilities

• Maintain, safeguard, and ensure the integrity of all patient health records, including oversight of record accuracy, completeness, confidentiality, auditing processes, and lawful disclosure in accordance with federal, state, and organizational requirements.
• Ensure all medical records are complete, timely, accurate, and compliant with applicable regulations, including documentation standards, signature requirements, and established timelines (e.g., 24-hour, 48-hour, or business-day requirements as defined by policy and payer expectations).
• Accurately scan, index, upload, and validate documents within the Electronic Medical Record (EMR), ensuring proper patient matching, document type classification, and image quality to support clinical, legal, and billing functions.
• Perform reconciliation and maintenance of inactive, discharged, or archived records, including verification of record completeness, closure of outstanding deficiencies, and adherence to retention and purging schedules.
• Verify and maintain the accuracy of patient demographic, encounter, and provider data within the EMR, ensuring data integrity for clinical care, reporting, billing, and regulatory compliance.
• Process requests for medical records in strict compliance with HIPAA, 42 CFR Part 2, and applicable state laws, including validation of authorizations, application of the minimum necessary standard, and secure release of information.
• Maintain detailed and accurate documentation of all disclosures, including completion of disclosure logs and accounting of disclosures as required by regulatory standards.
• Conduct assigned medical record audits to evaluate documentation quality, completeness, timeliness, and regulatory compliance, and promptly report findings, trends, and deficiencies to the Health Information Supervisor and/or Quality Management.
• Assist in preparation for and participation in internal and external audits (e.g., CARF, AHCA, DCF, Medicaid, and other regulatory bodies), including gathering documentation, responding to audit requests, and implementing corrective actions as directed.
• Provide timely, accurate, and professional responses to requests for medical records from staff, patients, and authorized third parties, ensuring compliance with confidentiality requirements and organizational service standards.
• Assist patients, family members and 3rd parties with accurate completion of the release of information, to include face to face assistance where appropriate.

Benefits

• Full-time Dental, vision, health, and life insurance.
• Employee Assistance Program (EAP).
• Employer sponsored contribution to Health Savings Account (HSA), with qualifying insurance plan.
• Paid Time Off (PTO).
• 11 paid holidays.
• 403b Retirement Plan, with 9% employer contribution for those who meet eligibility requirements.
• Tuition reimbursement, Public Service Loan Forgiveness (PSLF) eligible, and Health Resources and Services Administration (HRSA) loan repayment eligible for qualifying staff

What This Job Offers

• Job Type: Part-time
• Career Level: Entry Level
• Education Level: High school or GED