Senior Executive, Medical Records

Sunway Medical Centre; Ipoh; On-site; MYR 200,000 - 250,000; Full time

Job summary

A healthcare facility in Ipoh is looking for a professional to oversee Medical Records operations, ensuring compliance with statutory requirements and quality standards. The role includes managing daily operations, conducting audits, and working with stakeholders to improve compliance. Candidates should have a degree in Health Information Management, experience in medical records, and knowledge of ICD-10 coding. This position offers opportunities for leadership and improvement initiatives in a hospital setting.

Qualifications

• Degree in Health Information Management or equivalent required.
• ICD-10 coding training or certification necessary.
• Up to 3 years of experience in Medical Records services, supervisory role preferred.

Responsibilities

• Lead daily Medical Records operations and ensure compliance with regulations.
• Conduct audits on medical record policies and collaborate with stakeholders.
• Monitor operational costs and provide reports to department heads.

Skills

Health Information Management

ICD-10 coding

Quality improvement

Education

Degree in Health Information Management / Record Management

Job description

Responsible in leading and monitoring daily Medical Records operation and projects by driving continuous quality improvement in compliance with statutory regulations, legislations and accreditation requirements and ensuring Medical Records staff and users comply with the hospital policies and procedures thereby achieving the department’s goals. Responsible for maintaining and securing all written and electronic medical records and ensuring that information contained in the record is complete, accurate, and only available to authorized personnel. Responsible for effective, efficient and responsive to day-to-day health records management service delivery, ensure timely completion of medical reports and insurance, ensure correct arrangement and filing of patient records, ICD 10 and procedure coding, and notification of communicable diseases in compliance with MOH and legislative requirements.

Core Duties

• Ensure effective and efficient day-to-day health records management service by ensuring there are adequate staff and supplies, conduct regular meeting, and lead in the process improvement initiatives.
• To plan, coordinate & conduct audits on compliance to medical record policies, collaborate with other stakeholders and execute actions to close gaps to improve performance, compliance and service standards.
• Communicate to the staff on the department performance indicator and monitoring such as the Turn Around Time on retrieving adhoc request, appointment folder preparation, filing and coding completion, medical reports/insurance completion, and notification of communicable diseases within the predefined standards.
• Monitor operational costs (e.g. OT claims and casual wedges) and external vendor’s agreements (tenancy, records management, etc.) and provide monthly inventory report and analysis to the HODs in ensuring smooth running of the department.
• Develop in-house work manuals, training programmes and materials, and evaluate the technical competencies of staffs.
• Work closely with doctors and relevant stakeholders to improve compliance to requirements of medical record handling, policies and procedures, documentation and reporting to healthcare authorities.
• Investigate and review e-incidents and customer complaints and implement corrective and preventive actions to mitigate risks and comply to the required standards.

Qualifications & Requirements

• Degree in Health Information Management / Record Management, or equivalent.
• Trained in ICD-10 disease classification and procedure coding, gained via related degree / diploma education or training certification.
• Generally, would have acquired up to 3 years of working experience in Medical Records department services, with up to 1 years at an increasingly responsible executive level position and with supervisory experience in a hospital setting.
• Extensive knowledge of the overall functions and processes of medical records department services, quality improvement, and staffing.
• Working knowledge of disease notifications and mandatory reporting requirements, birth and death registrations, MOH and legislative requirements, efficient medical folder and document filing and archiving systems and use of electronic or computerized systems.
• Working knowledge of requirements for medical records services described in the Private Healthcare Facilities and Services Act, Personal Data Protection Act and other related Acts, regulations and accreditation standards.