Assistant Medical Records Manager

Cengild G.I. Medical Centre; Kuala Lumpur; On-site; MYR 60,000 - 110,000; Full time

Job summary

Cengild G.I. Medical Centre in Kuala Lumpur is seeking an experienced Medical Records Manager to lead the Medical Records Unit, oversee EMR workflows and ensure compliance with PDPA and CKAPS.

You will supervise staff, coordinate with IT for EMR improvements, manage filing, retention, and release of information, and act as Secretary to the Medical Records Committee.

Qualifications

• Experience in medical records management and EMR systems.
• Knowledge of PDPA and Malaysian private healthcare regulatory requirements.
• Ability to supervise and train Medical Records Unit staff.

Responsibilities

• Manage daily operations, manpower and workflow of the Medical Records Unit.
• Ensure proper filing, retrieval, storage, archiving and retention of medical records.
• Ensure timely availability of medical records to authorised users.
• Monitor missing, incomplete records and follow up.
• Oversee EMR scanning, uploading, indexing, and quality control.
• Coordinate EMR issues with IT and clinical departments.
• Oversee ICD-10 coding and reporting accuracy.
• Process medical reports and release of information with patient consent.
• Maintain confidentiality and security of patient information.
• Act as Secretary to the Medical Records Committee and prepare agenda/minutes.

Skills

Medical Records Management

EMR/HIS

ICD-10/ICD-11 coding

Regulatory compliance

Tools

EMR system

Job description

Jora Malaysia will close on 9th September 2026. Thank you for being with us, we are cheering you on as you continue your career journey.

• Manage the daily operations, manpower and workflow of the Medical Records Unit.
• Ensure proper filing, retrieval, tracking, storage, archiving and retention of medical records.
• Ensure timely availability of medical records to authorised users.
• Monitor missing, incomplete, duplicate or untraceable records and ensure appropriate follow-up.
• Ensure proper retention and secure disposal of medical records in accordance with applicable requirements.

Electronic Medical Records (EMR)

• Oversee and perform timely scanning and uploading of required documents into the EMR.
• Ensure uploaded documents are complete, legible and correctly indexed to the correct patient and encounter.
• Monitor missing, duplicate or incorrectly uploaded documents and ensure timely rectification.
• Coordinate with IT and relevant departments on EMR issues, downtime processes, and system improvements.

Medical Coding, Statistics & Statutory Reporting

• Oversee accurate and timely ICD-10 coding and reporting based on clinical

Medical Reports & Release of Information

• Oversee processing of medical reports and requests for copies of medical records.
• Ensure information is released only with appropriate patient consent or other authorised basis.
• Monitor turnaround time for medical reports and record requests.
• Ensure confidentiality and proper documentation of all information released.

Medical Records Quality & Governance

• Serve as Secretary to the Medical Records Committee, including preparation of agenda, minutes, reports and follow-up of action items.
• Coordinate and oversee closed medical record/chart reviews to monitor completeness, accuracy and compliance with documentation requirements.
• Identify incomplete or deficient documentation and coordinate follow-up with the responsible doctors/departments.
• Monitor outstanding and delinquent medical records and escalated prolonged non-compliance where required.
• Develop, review and maintain the hospital’s Approved Abbreviations List in consultation with relevant clinical stakeholders.
• Coordinate approval and periodic review of the abbreviation lists through the appropriate hospital governance process.
• Analyse and present documentation deficiencies, trends and Medical Records indicators to the Medical Records Committee.
• Monitor corrective and improvement actions arising from chart reviews, audits and committee decisions.
• Ensure confidentiality, privacy and security of patient information.
• Ensure compliance with applicable Malaysian private healthcare requirements, PDPA, PHFS Act 1998 /CKAPS requirements, accreditation standards and hospital policies.
• Maintain readiness for regulatory inspections, accreditation surveys and internal/external audits.
• Coordinate corrective actions arising from audit or regulatory findings.
• Escalate confidentiality breaches, loss of records or significant documentation issues to Management.
• Supervise, train and evaluate Medical Records Unit staff.
• Plan manpower and allocate duties according to operational requirements.
• Develop, implement and review Medical Records policies, SOPs and workflows.
• Ensure staff competency in medical records management, EMR, coding and confidentiality requirements.
• Monitor unit performance and implement continuous improvement initiatives.

Confidentiality, Regulatory & Quality Compliance

• Ensure confidentiality, privacy and security of patient information.
• Ensure compliance with applicable Malaysian private healthcare requirements, PDPA, PHFS Act 1998 /CKAPS requirements, accreditation standards and hospital policies.
• Maintain readiness for regulatory inspections, accreditation surveys and internal/external audits.
• Coordinate corrective actions arising from audit or regulatory findings.
• Escalate confidentiality breaches, loss of records or significant documentation issues to Management.

PREFERENCE

Knowledge of ICD-10 and ICD-11, medical records management, EMR/HIS, PDPA and Malaysian private healthcare regulatory requirements.

Medical records and health information management