Medical records manager

Medical records managers are responsible for managing activities of medical records units which maintain and secure patient data. They supervise, oversee and train employees while implementing medical department policies.

Excludes people performing patients treatment or medical treatment assistance.

The duties of a medical records manager include, but are not limited to:

• Creating and updating patient charts, including recording test results and other medical information about each patient
• Coordinating with healthcare providers to ensure that all records are up to date and accessible
• Reviewing files to identify incomplete information or discrepancies, such as missing test results or unclear diagnosis codes
• Organizing and maintaining medical records in accordance with federal regulations and state laws
• Ensuring confidentiality of patient information
• Communicating with patients and other medical staff regarding test results and treatment plans
• Scheduling appointments and ensuring that appointments begin on time using computerized scheduling systems
• Communicating with insurance companies and third party payors regarding claim denials and appeals processes
• Maintaining documentation for each patient’s care plan, including daily logbooks of physician orders, treatments received, and test results
• Providing administrative support for the clinical operations of a healthcare facility by maintaining medical records for patients

The following job titles also refer to medical records manager:

supervisor of medical records
health records manager
health records supervisor
medical records supervisor
supervisor of patient records
manager of medical records
director of medical records
patient records manager
manager of patient records
senior medical records officer
patient records supervisor
manager of health records

Medical records managers often work onsite at a hospital, medical clinic, or other types of healthcare facilities. They must maintain proximity to any patient medical records they are responsible for maintaining. This means medical records managers ]maintain offices not far from the healthcare staff that needs to access pertinent medical records.

Ultimately, the location where a medical records manager works will be determined by their employer. Since many patient records today are digitized and can be accessed remotely, medical records managers are beginning to experience some flexibility in their location of employment.

Candidates interested in becoming medical records managers must first obtain a bachelor’s degree, in addition to any related certifications. This education regimen often includes a degree from an online nursing or health program.

Medical records managers must become familiar with both a healthcare setting, and with the necessary record-keeping practices that will define their day-to-day practices. At a minimum, a medical records manager will need to receive an undergraduate degree in health information management. This type of degree program will review both the healthcare fundamentals involved in medical records, as well as the technical aspect and software systems that record managers will need to know in order to be successful. 

ISCO skill level is defined as a function of the complexity and range of tasks and duties to be performed in an occupation. It is measured on a scale from 1 to 4, with 1 the lowest level and 4 the highest, by considering:

• the nature of the work performed in an occupation in relation to the characteristic tasks and duties
• the level of formal education required for competent performance of the tasks and duties involved and
• the amount of informal on-the-job training and/or previous experience in a related occupation required for competent performance of these tasks and duties.

Medical records manager is a Skill level 3 occupation.

These occupations, although different, require a lot of knowledge and skills similar to medical records manager.

clinical coder
medical transcriptionist
medical records clerk
waiting list coordinator
chiropractic assistant

These occupations require some skills and knowledge of medical records manager. They also require other skills and knowledge, but at a higher ISCO skill level, meaning these occupations are accessible from a position of medical records manager with a significant experience and/or extensive training.

clinical informatics manager
orthoptist
healthcare institution manager
podiatry assistant
acupuncturist

This knowledge should be acquired through learning to fulfill the role of medical records manager.

• Health care legislation: The patients` rights and responsibilities of health practitioners and the possible repercussions and prosecutions in relation to medical treatment negligence or malpractice.
• Database: The classification of databases, that includes their purpose, characteristics, terminology, models and use such as XML databases, document-oriented databases and full text databases.
• Health records management: The procedures and importance of record keeping in a healthcare system such as hospitals or clinics, the information systems used to keep and process records and how to achieve maximum accuracy of records.
• Professional documentation in health care: The written standards applied in the health care professional environments for documentation purposes of one`s activity.
• Data storage: The physical and technical concepts of how digital data storage is organised in specific schemes both locally, such as hard-drives and random-access memories (RAM) and remotely, via network, internet or cloud.
• Manage healthcare staff: The managerial tasks and responsibilities required in a health care setting.
• Medical informatics: The processes and tools used for the analysis and dissemination of medical data through computerized systems.
• Clinical coding: The matching of clinical statements with standard codes of illnesses and treatments through use of a classification system.
• Document management: The methodology of tracking, managing and storing documents in a systematic and organised manner as well as keeping a record of the versions created and modified by specific users (history tracking).

These skills are necessary for the role of medical records manager.

• Undertake clinical audit: Undertake internal clinical audit through the collection of statistical, financial and other data related to service delivery.
• Use e-health and mobile health technologies: Use mobile health technologies and e-health (online applications and services) in order to enhance the provided healthcare.
• Archive healthcare users’ records: Properly store the health records of healthcare users, including test results and case notes so that they are easily retrieved when required.
• Recruit employees: Hire new employees by scoping the job role, advertising, performing interviews and selecting staff in line with company policy and legislation.
• Manage healthcare users’ data: Keep accurate client records which also satisfy legal and professional standards and ethical obligations in order to facilitate client management, ensuring that all clients’ data (including verbal, written and electronic) are treated confidentially.
• Use electronic health records management system: Use specific software for the management of health care records, following appropriate codes of practice.
• Manage information in health care: Retrieve, apply and share information among patients and healthcare professionals and across healthcare facilities and community.
• Communicate effectively in healthcare: Communicate effectively with patients, families and other caregivers, health care professionals, and community partners.
• Follow clinical guidelines: Follow agreed protocols and guidelines in support of healthcare practice which are provided by healthcare institutions, professional associations, or authorities and also scientific organisations.
• Evaluate employees: Analyse employees’ individual performance over a certain time span and communicate own conclusions to the employee in question or higher management.
• Supervise staff: Oversee the selection, training, performance and motivation of staff.
• Identify patients’ medical records: Locate, retrieve and present medical records, as requested by authorized medical personnel.
• Comply with legislation related to health care: Comply with the regional and national legislation that is relevant to one`s work and apply it in practice.
• Collect statistics on medical records: Perform statistical analysis of various medical records of the healthcare facility, referring to the number of hospital admissions, discharges or waiting lists.
• Work in a multicultural environment in health care: Interact, relate and communicate with individuals from a variety of different cultures, when working in a healthcare environment.
• Apply organisational techniques: Employ a set of organisational techniques and procedures which facilitate the achievement of the goals set. Use these resources efficiently and sustainably, and show flexibility when required.
• Oversee record management: Control and oversee electronic records of an organisation throughout the records life-cycle.
• Work in multidisciplinary health teams: Participate in the delivery of multidisciplinary health care, and understand the rules and competences of other healthcare related professions.
• Perform clinical coding procedures: Match and record correctly the specific illnesses and treatments of a patient by using a clinical codes classification system.
• Manage digital archives: Create and maintain computer archives and databases, incorporating latest developments in electronic information storage technology.
• Participate in medical records’ auditing activities: Assist and help with any requests arisen during audits related to the archiving, filling and processing of medical records.

This knowledge is sometimes, but not always, required for the role of medical records manager. However, mastering this knowledge allows you to have more opportunities for career development.

• Customer service: Processes and principles related to the customer, client, service user and to personal services; these may include procedures to evaluate customer’s or service user’s satisfaction.
• Medical terminology: The meaning of medical terms and abbreviations, of medical prescriptions and various medical specialties and when to use it correctly.
• Bookkeeping regulations: The methods and regulations involved in the process of accurate bookkeeping.
• Human physiology: The science that studies the human organs and its interactions and mechanisms.
• Risk management: The process of identifying, assessing, and prioritising of all types of risks and where they could come from, such as natural causes, legal changes, or uncertainty in any given context, and the methods on dealing with risks effectively.
• Health care system: The structure and function of health care services.
• Human anatomy: The dynamic relationship of human structure and function and the muscosceletal, cardiovascular, respiratory, digestive, endocrine, urinary, reproductive, integumentary and nervous systems; normal and altered anatomy and physiology throughout the human lifespan.
• Patient record storage: Field of information which monitors regulatory and legal changes regarding patient record compilation and storage.

These skills and competences are sometimes, but not always, required for the role of medical records manager. However, mastering these skills and competences allows you to have more opportunities for career development.

• Carry out records management: Manage the life-cycle of records of institutions, indivduals, corporate bodies, collections, oral history.
• Monitor regulations in social services: Monitor and analyse regulations, policies and changes in these regulations in order to assess how they impact social work and services.
• Manage budgets: Plan, monitor and report on the budget.
• Answer patients’ questions: Respond in a friendly and professional manner to all inquiries from current or potential patients, and their families, of a healthcare establishment.
• Record treated patient’s information: Record information accurately relating to the progress of the patient during therapy sessions.
• Maintain healthcare user data confidentiality: Comply with and maintain the confidentiality of healthcare users` illness and treatment information.
• Advise medical staff: Act as a consultant to medical staff by providing advice on medical records policies.
• Interview people: Interview people in a range of different circumstances.
• Manage workflow processes: Develop, document and implement traffic and workflow processes across the company for different functions. Liaise with several departments and services such as account management and the creative director to plan and resource work.
• Collect healthcare user’s general data: Collect qualitative and quantitative data related to the healthcare user’s anagraphic data and provide support on filling out the present and past history questionnaire and record the measures/tests performed by the practitioner.
• Record healthcare users’ billing information: Record the healthcare user`s information for the billing of provided medical services.
• Supervise daily information operations: Direct daily operations of different units. Coordinate program/project activities to assure the respect of costs and time.
• Meet the requirements of social security reimbursement bodies: Ensure that the sessions are compliant with the requirements of the national social security bodies and that reimbursements are acceptable.
• Perform backups: Implement backup procedures to backup data and systems to ensure permanent and reliable system operation. Execute data backups in order to secure information by copying and archiving to ensure integrity during system integration and after data loss occurrence.
• Maintain treatment records: Keep accurate records and file reports related to the prescribed treatment or medication.
• Review patient’s medical data: Assess and review relevant medical data of patients such as X-rays, medical history and laboratory reports.
• Transfer medical information: Extract information from a patient’s notes and enter them in a computer programme.
• Process data: Enter information into a data storage and data retrieval system via processes such as scanning, manual keying or electronic data transfer in order to process large amounts of data.
• Formulate a treatment plan: Formulate a treatment plan and evaluation analysis based on collected data following assessment using a clinical reasoning process.

3252 – Medical records and health information technicians

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References

1. Medical records manager – ESCO
2. Medical Records Manager Job Description: Salary, Duties, & More – Climb the Ladder
3. What is a Medical Records Manager Career? – WGU.edu
4. Featured image: Photo by Nataliya Vaitkevich from Pexels