Key Responsibilities
Intake & Tracking
- Receive, log, and track all incoming medical records requests (email, patient portal, secure fax, mail, subpoenas, court orders, payer and Medicare requests).
- Acknowledge receipt using approved templates and maintain ongoing status communication.
Authorization & Legal Validation
- Verify identity and authority of requestors.
- Validate authorizations for scope, purpose, expiration, and minimum necessary standards.
- Identify special protections (e.g., 42 CFR Part 2, psychotherapy notes, HIV/STD results, minor records, third-party information).
- Review subpoenas, court orders, payer audits, and Medicare documentation requests.
- Escalate legal, complex, or unclear requests to Privacy/Compliance and the Lead Accounting Assistant.
Clinical & Provider Clearance
- Route all proposed record disclosures to treating clinicians and psychiatric/psych prescribing providers (as applicable) for review and written approval prior to release.
- Document approvals, restrictions, redactions, or holds in the ROI log.
- Place releases on hold and escalate if providers identify clinical risk or contraindications.
Record Preparation & Fulfillment
- Retrieve designated records from the EHR or document repository.
- Assemble, paginate, label, and redact records per policy and provider guidance.
- Apply secure encryption and approved delivery methods (secure email, portal, or secure fax).
- Maintain complete documentation including date/time, recipient, contents, delivery method, and authorizing documents.
Timeliness, Quality & Audits
- Meet internal SLAs and all federal/state response timelines, including CMS requirements for Medicare records.
- Perform quality checks prior to release to ensure accuracy and compliance.
- Participate in ROI, payer, and Medicare audits and remediate findings promptly.
Compliance & Information Security
- Strictly adhere to HIPAA, privacy, confidentiality, and records retention standards.
- Apply the minimum necessary standard for all disclosures.
- Follow remote security protocols including VPN, MFA, approved devices, and private workspace requirements.
- Immediately report and escalate potential privacy incidents or mis disclosures per policy.
Collaboration & Communication
- Work closely with Privacy/Compliance, Lead Accounting Assistant, clinicians, psychiatric providers, Admissions, and external partners.
- Maintain clear, professional, trauma-informed, and family-centered email communication.
- Contribute to SOPs, templates, and process improvements related to records management.
Required Qualifications
- 2+ years of experience in medical records, release of information, health information management, or healthcare documentation.
- Strong working knowledge of HIPAA privacy/security and the minimum necessary standard.
- Familiarity with behavioral health records and heightened confidentiality requirements.
- Excellent written communication skills in an email-centric role.
- High attention to detail with document handling, redaction, and file organization.
- Proficiency with EHR systems, secure email/encryption tools, eFax, and Microsoft 365 or Google Workspace.
Preferred Qualifications
- Experience with adolescent or family-based behavioral health programs.
- Knowledge of ROI nuances related to minors, guardianship, custody orders, and psychotherapy notes.
- Experience with payer audits or Medicare documentation.
- RHIT, CHDS, CHPS, or similar certification (or progress toward certification).
Core Competencies
- Accuracy & Quality: Zero-defect approach to authorizations, approvals, redactions, and logs.
- Confidentiality & Ethics: Sound judgment with sensitive patient and family information.
- Time Management: Ability to prioritize high-volume requests by deadline and risk.
- Customer Service: Clear, respectful, and professional communication.
- Accountability: Follows policy precisely and documents every step.
