Senior Medical Records Technician

The SR Medical Records Tech will be responsible to review and analyze inpatient and ambulatory surgery medical records. Will review medical records for accuracy of pertinent documents, completeness of the physician signatures and other medical professional data entries. Will collaborate with the Medical Staff Office to report medical record deficiencies. Support the medical staff in the completion of the medical record and facilitate medical record availability.

• Review discharged patient medical records for completeness and accuracy, based on hospital policy and accreditation and regulatory standards.
• Input incomplete data elements into delinquency database.
• Facilitate medical record availability for physician completion and retrieve medical records; contact physicians to inform them of the availability of the medical record for review and signature; re-review the medical record following physician review and signature activity.
• Monitor database to identify physicians with incomplete medical records; draft and send physician an incomplete medical record notification letter.
• File operative reports in the medical record.
• Perform clinical pertinence review of medical records per hospital policy and procedures; prepare medical record deficiency reports as needed by management.

• Minimum Education:
  
  High School Diploma or GED (Required)
• Minimum
  
  Work Experience:
  
  2 years experience in processing and/or maintenance of medical records (Required)
• Strong knowledge of medical record content and identification of documents is required.
• Must be reliable and trustworthy, maintaining strict confidentiality of sensitive information.
• Demonstrates excellent communication skills and the ability to problem solve.
• Presents self in a professional manner at all times.
• Exhibits confidence and courtesy when addressing the medical staff.
• Ability to meet quality and quantity productivity standards set by the medical records industry.
• Demonstrates proficiency in all clerical functions of medical records management.
• Demonstrated competency in computer skills and ability to operate in a Windows environment such as Microsoft Office and Word.

• This job description is not to be construed as an exhaustive statement of duties, responsibilities, or requirements.
• Employees will be required to perform any other job-related instructions given by their supervisor, subject to reasonable accommodation.

• Seek educational opportunities related to medical records review and analysis.
• Participate in educational/in-service offerings presented by the Human Resources Department.

• Participate in the CNMC's customer service education program.
• Extend assistance to all customers of the HIM Department.

• Partner in the mission and uphold the core principles of the organization.
• Committed to diversity and recognizes the value of cultural and ethnic differences.
• Demonstrate personal and professional integrity.
• Maintain confidentiality at all times.

• Demonstrate collaborative and respectful behavior.
• Partner with all team members to achieve goals.
• Receptive to others’ ideas and opinions.
• Contribute to a positive work environment and demonstrate flexibility and willingness to change.
• Identify opportunities to improve clinical and administrative processes and make appropriate decisions using sound judgment.

• Use resources efficiently and seek less costly ways of doing things.

• Speak up when team members appear to exhibit unsafe behavior or performance.
• Continuously validate and verify information needed for decision making or documentation.
• Stop in the face of uncertainty and take time to resolve the situation.
• Demonstrate accurate, clear and timely verbal and written communication.
• Actively promote safety for patients, families, visitors and co-workers.
• Attend carefully to important details, practicing Stop, Think, Act and Review to self-check behavior and performance.

Functional Locations:
Primary

Location:

Maryland-Silver Spring;
Work Locations:
Dorchester

Job:
Health Information Management and Coding | Organization:
Finance

Position Status: R (Regular) | Shift:
Day | Work Schedule:
Monday - Friday 6:00 AM - 6:00 PM

Job Posting:
Jan 21, 2026, 10:57:44 PM

Full-Time Salary Range: 49254.4