MEDICAL RECORDS SPECIALIST

Arizona Department of Administration•Phoenix, AZ

1d•Onsite

About The Position

The Health Records Compliance Manager reports to the Director of Health Records and is responsible for supporting the compliance program and ensuring the operational integrity of Health Records for ACPTC. This role coordinates and executes health information initiatives, ensuring alignment with regulatory, legal, and accreditation standards, as well as organizational policies. This position is accountable for ensuring the accuracy, completeness, and timeliness of patient documentation throughout the continuum of care—from admission through discharge—while maintaining full compliance with federal and state regulations, accrediting agencies, and internal compliance requirements. Key responsibilities include: Supporting compliance activities related to health records, including monitoring documentation practices, conducting chart audits, and generating compliance and risk reports. Contributing to performance improvement initiatives by identifying documentation trends, gaps, and areas for regulatory improvement, and assisting in the development of corrective actions. Collaborating with interdisciplinary clinical staff—including physicians, nurses, social workers, psychologists, nutrition services, and rehabilitation therapists—to facilitate timely, accurate, and compliant completion of medical records. Assisting in the development, implementation, and monitoring of key performance indicators (KPIs) and compliance metrics to ensure high-quality documentation and regulatory adherence. Ensuring the integrity, security, and reliability of medical records by verifying that all documentation is accurate, properly maintained, and correctly attributed to each patient. Supporting HIPAA compliance within the Health Records function, including appropriate handling of protected health information (PHI) and assisting with redaction processes for internal and external reporting. Assisting with electronic health record (EHR) processes, including scanning, indexing, document quality review, and data integrity to maintain complete and accurate electronic records. Supporting audits, surveys, and accreditation activities by preparing documentation and ensuring records meet compliance standards. The Health Records Compliance Manager plays a key role in supporting compliance efforts, strengthening documentation practices, improving workflows, and maintaining high standards of accuracy and regulatory adherence across the Health Records Department at ACPTC.

Requirements

Knowledge of: -Medical terminology and anatomy;
Accepted methods and techniques in maintenance of medical records;
Laws, rules and regulations regarding medical records;
Medical record documentation standards as established by the Joint Commission, CMS standards and state licensing regulations;
Hospital rules and regulations relating to documentation requirements in the health record;
HIPAA requirements for protected health information;
Personal computer software (ie. Word, Excel) as well as an electronic health record system.
Knowledge of the performance management (PM) model and continuous quality improvement (CQI) methods in a public health setting.
Skill In: -Interpersonal skills to interact with a variety of professional and para-professional staff, the patients and the public; oral and written communication;
Detail-oriented; skills in filing complex medical information and documents;
The ability to concentrate for long periods of time;
Audit skills to determine the completeness and accuracy of medical record documentation;
Computer skills in a variety of software packages applicable to medical records management;
Time management. Strong auditing and analytic skills to review medical records and data to identify areas of deficiencies.
Ability to: -Maintain confidentiality;
Accurately and efficiently file and scan documents;
The ability to use a variety of office equipment ie. fax, scanner, copier, computer, printer.
Ability to ensure compliance with multiple regulatory standards while maintaining efficiency and accuracy.
Ability to manage and prioritize multiple tasks, deadlines, and compliance activities simultaneously.
Ability to maintain confidentiality and exercise sound judgment when handling protected health information (PHI)Ability to identify trends, risks, and gaps in documentation and contribute to performance improvement efforts.
Ability to work independently while supporting departmental and organizational goals.
Ability to adapt to changing regulations, systems, and organizational needs
This position is required to perform work at/attend meetings at alternate locations and/or travel when necessary.
Driver's License.
State hospital employee must possess a valid level one fingerprint clearance card issued pursuant to A.RS. 41-1758.07 or must apply for a level one clearance fingerprint clearance card within seven working days after beginning employment.
NOTE: If position is required to drive on state business, the position will require the possession of and ability to drive.
“This position is subject to the vaccination requirements outlined in CMS Interim Final Rule - Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination (published November 5, 2021) (86 FR 61555).”
All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Nice To Haves

Preference will be given to candidates with two years of medical records experience.

Responsibilities

Leads and coordinates health records compliance activities by evaluating documentation practices across the continuum of care to ensure adherence to regulatory and accreditation standards. Conducts targeted and system-wide chart audits to identify trends, risks, and compliance gaps. Analyzes findings and develops risk reports, dashboards, and recommendations for leadership. Monitors ongoing compliance with federal/state regulations and accreditation standards. Supports organizational readiness for audits, surveys, and accreditation reviews.
Drives documentation quality improvement initiatives through data analysis, KPI tracking, and process enhancement. Identifies documentation trends and systemic issues, recommending corrective actions. Assists in development and monitoring of KPIs and compliance metrics. Collaborates on performance improvement initiatives to strengthen documentation practices. Supports implementation of corrective action plans and evaluates effectiveness.
Facilitates timely, accurate, and compliant documentation by working across clinical disciplines without direct supervision authority. Collaborates with physicians, nursing, and allied health staff to resolve documentation deficiencies. Provides guidance and clarification on documentation standards and compliance expectations. Acts as a liaison between Health Records and clinical teams to improve workflow efficiency. Supports education efforts related to documentation compliance and regulatory requirements.
Ensures the reliability, accuracy, and integrity of electronic health records while maintaining full compliance with privacy, security, and regulatory requirements. Oversees data integrity processes including document quality review, indexing, and record completeness, and evaluates EHR workflows to recommend and implement process improvements that enhance accuracy and efficiency. Ensures all documentation is properly attributed and maintained within the legal medical record and supports the ongoing optimization of electronic documentation systems. Monitors and enforces compliance with HIPAA and organizational privacy policies by ensuring appropriate handling, redaction, and release of protected health information (PHI). Assists with internal and external information requests and reporting requirements, and proactively identifies, evaluates, and escalates potential compliance risks related to data integrity and information security.
Other duties as assigned as related to the position (typically 5% - 10%)