Medical Records & Compliance Specialist

Pantai Hospital Penang; Bayan Lepas; On-site; MYR 60,000 - 90,000; Full time

Job summary

Pantai Hospital Penang is seeking a dedicated Medical Records professional to manage daily operations, ensure compliance with national acts and accreditation standards, and support documentation quality across wards and departments.

The role includes chart reviews, staff training, and maintaining orderly filing while coordinating monthly rosters and quality improvement activities within the Medical Records Department.

Responsibilities

• Documents, implements and reviews policies and procedures in liaison with the Medical-Record-In-Charge.
• Organizes, directs, controls and evaluates daily operations; develops and implements a quality assurance system to meet medical records management and policy requirements.
• Ensures medical records contents are efficiently handled by Ward Clerks who provide clerical support to Nursing Staff in all wards; includes filing discharge folders and incomplete discharge summaries by consultants.
• Ensures compliance with the Private Healthcare Facilities and Services Act and directives from The Ministry of Health, Malaysia and hospital accreditation standards.
• Maintains efficient filing and retrieval of medical records to provide excellent service to Doctors, wards and other departments.
• Oversees smooth operations of Medical Records department functions under the C-plus system and One Stop Center; handles queries from Consultants, Sister on call, Staff Nurse, Clinic Assistant.
• Ensures timely submission of statutory requirements and notifications to the Ministry of Health.
• Performs chart reviews with the Chart Review Committee and conducts compliance audits for initial doctor assessments and discharge summaries.
• Maintains competency and provides training to new staff in all department functions and discharge diagnosis coding (ICD-11).
• Evaluates accuracy of discharge diagnosis coding and procedure codes.
• Maintains neat and orderly filing and storage in compactors and shelves.
• Responsible for monthly staff roster and quality improvement activities in the MR Department.
• Compiles monthly statistics and reports to ensure on-time submissions to Administration and related departments.
• Ensures achievement of accreditation and certification standards for medical records services.
• Provides in-service training for existing and new staff as assigned by the Medical Record Officer-In-Charge.
• Performs other appropriate tasks and duties as needed and participates in community service when required.

Job description

Pantai Hospital Penang is seeking a dedicated Medical Records professional to manage daily operations, ensure compliance with national acts and accreditation standards, and support documentation quality across wards and departments.

The role includes chart reviews, staff training, and maintaining orderly filing while coordinating monthly rosters and quality improvement activities within the Medical Records Department.