Job Description – Medical Records Executive
Hospital Industry (Experienced Candidate – Medical Records Department)
Position Title
Medical Records Executive
Department
Medical Records Department (MRD)
Reporting To
Medical Records Manager / MRD In-Charge / Hospital Administrator
Job Location
Hospital / Healthcare Facility
Job Summary
The Medical Records Executive is responsible for the accurate collection, maintenance, storage, retrieval, and management of patient medical records in compliance with hospital policies, legal requirements, accreditation standards, and confidentiality regulations. The role ensures timely availability of medical records for patient care, audits, insurance claims, medico-legal purposes, research, and statutory requirements.
The ideal candidate should possess prior experience in the Medical Records Department (MRD) within a hospital setting and demonstrate strong organizational skills, attention to detail, and knowledge of healthcare documentation systems.
Key ResponsibilitiesMedical Records Management
- Maintain complete and accurate inpatient, outpatient, emergency, and day-care patient records.
- Ensure proper filing, indexing, coding, storage, and retrieval of medical records.
- Verify completeness of patient records before filing and closure.
- Monitor documentation deficiencies and coordinate with clinicians for timely completion.
- Maintain medical records in accordance with hospital policies and statutory guidelines.
- Ensure proper record retention and archival management.
Documentation & Record Maintenance
- Review patient files for completeness, accuracy, signatures, dates, and required documentation.
- Ensure discharge summaries, consent forms, operative notes, investigation reports, and treatment records are appropriately documented.
- Track incomplete records and follow up with concerned departments.
- Maintain patient master indexes and record tracking systems.
Electronic Medical Records (EMR/EHR)
- Update and maintain electronic medical records accurately.
- Ensure proper scanning, digitization, and uploading of patient documents.
- Support implementation and maintenance of Hospital Information Systems (HIS) and Electronic Medical Records (EMR).
- Verify data accuracy and resolve documentation discrepancies.
Coding & Statistical Reporting
- Assist in disease and procedure coding using ICD standards as applicable.
- Generate daily, monthly, and annual statistical reports.
- Maintain departmental records and healthcare statistics.
- Support data analysis for hospital quality indicators and management reports.
Insurance & Medicolegal Support
- Provide medical records required for insurance claims processing.
- Assist in preparation of records for medicolegal cases while maintaining confidentiality.
- Coordinate with insurance, legal, and audit teams regarding record requests.
- Ensure records are released only after obtaining proper authorization.
Accreditation & Compliance
- Ensure compliance with hospital policies and regulatory requirements.
- Support accreditation activities including National Accreditation Board for Hospitals & Healthcare Providers standards and other healthcare quality requirements.
- Participate in internal and external audits.
- Maintain documentation required for quality assurance programs.
Confidentiality & Data Security
- Protect patient confidentiality and privacy at all times.
- Ensure secure handling, storage, and disposal of records.
- Follow applicable healthcare information security policies.
- Prevent unauthorized access to patient information.
Interdepartmental Coordination
- Coordinate with physicians, nursing units, laboratory, radiology, pharmacy, billing, and insurance departments.
- Facilitate timely retrieval and movement of records as required.
- Support departmental workflow improvements and process standardization.
Required QualificationsEducation
- Bachelor's Degree in Medical Records Science, Health Information Management, Hospital Administration, Life Sciences, or related field.
- Diploma/Certification in Medical Records Management or Health Information Management preferred.
Experience
- Minimum 2–5 years of experience in the Medical Records Department of a hospital.
- Experience in multi-specialty, tertiary care, gastroenterology, oncology, or accredited hospitals preferred.
- Hands-on experience with HIS/EMR systems.
Required Skills & Competencies
- Medical records management and documentation control.
- Knowledge of healthcare regulations and record retention policies.
- Understanding of ICD coding principles.
- Hospital Information System (HIS) proficiency.
- Electronic Medical Records (EMR/EHR) management.
- Data entry and record auditing skills.
- Strong organizational and analytical abilities.
- Attention to detail and accuracy.
- Excellent communication and coordination skills.
- Confidentiality and ethical conduct.
- Microsoft Office proficiency.
Key Performance Indicators (KPIs)
- Percentage of complete medical records maintained.
- Timeliness of record retrieval and filing.
- Documentation deficiency closure rate.
- Accuracy of patient record management.
- Compliance with accreditation standards.
- Turnaround time for record requests.
- Accuracy of data entry and EMR updates.
- Audit compliance scores.
- Patient confidentiality compliance.
- Reduction in record-related errors and discrepancies.
Working Conditions
- Hospital-based administrative role.
- May require handling physical and electronic medical records.
- Interaction with clinical, administrative, insurance, and legal departments.
- May require flexible working hours during audits, inspections, or accreditation activities.
Pay: ₹15,000.00 - ₹250,000.00 per month
Benefits:
Work Location: In person
