Medical Records Specialist

UHS•Newark, DE

About The Position

The Medical Records Specialist plays a critical role in maintaining the integrity, confidentiality, and accuracy of patient health records within a behavioral health hospital setting. This position is responsible for organizing, managing, and safeguarding medical documentation in compliance with federal, state, and organizational regulations, including HIPAA. The Specialist collaborates with clinical and administrative staff to ensure timely and accurate documentation, supports audits and quality improvement initiatives, and facilitates the release of information processes. The ideal candidate demonstrates attention to detail, strong organizational skills, and a commitment to supporting patient care through meticulous recordkeeping.

Requirements

High school diploma or equivalent required
Minimum of 1 year experience in a medical office or healthcare setting
Familiarity with medical terminology and EHR systems preferred
Excellent customer service and communication skills
Strong attention to detail and organizational abilities
Ability to handle sensitive information with discretion

Nice To Haves

Associate’s degree or completion of at least 12 college credits preferred
Familiarity with medical terminology and EHR systems preferred

Responsibilities

Maintain and update patient medical records in accordance with hospital policies and regulatory standards.
Ensure compliance with HIPAA and other privacy regulations when handling protected health information.
Process requests for release of information from patients, providers, and third parties, ensuring proper authorization and documentation.
Audit medical records for completeness and accuracy, identifying missing documentation or discrepancies.
Scan, index, and file medical documents into health record system in a timely and organized manner.
Collaborate with clinical and administrative staff to resolve documentation issues and support continuity of care.
Assist with chart preparation and record retrieval for internal and external audits, legal requests, and quality reviews.
Monitor record retention schedules and support secure destruction of outdated records per policy.
Respond to inquiries regarding medical records professionally and promptly, maintaining confidentiality at all times.
Stay current with changes in health information management practices, behavioral health documentation standards, and applicable regulations.
Performs other duties as assigned/required by this position.