Medical Records Auditor

Dr. Sulaiman Al Habib Medical Group; Saudi Arabia; On-site; SAR 200,000 - 300,000; Full time

Job summary

A leading healthcare organization in Saudi Arabia is seeking a Medical Records Coordinator to manage and review patient records, ensuring compliance with local and international standards. The role requires a bachelor's degree and specific nursing or medical qualifications, along with strong communication and data management skills. This position offers a chance to contribute significantly to the quality of patient care and documentation practices.

Qualifications

• Bachelor’s degree required.
• Preferred qualifications in Nursing or Medicine.
• Four years of experience in a medical records environment.

Responsibilities

• Review and complete medical records in accordance with standards.
• Collaborate with medical administration and quality departments.
• Ensure compliance with JCIA and CBAHI standards.

Skills

Good communication skills

Data gathering & assessment

Patient service

Data management & record keeping

Process management

Education

Bachelor’s Degree

Professional qualification in Nursing or Medicine and Surgery

Job description

Job Purpose / Objective

Monitor, review, and update patients' record files, both in-patient and out-patient, to ensure completeness and proper documentation in accordance with local and international standards.

Key Responsibilities / Accountabilities

• Review medical records from departments such as Emergency Department (ER), In-patient, and Out-patient based on review requirements, using established international and local standards.
• Organize and prioritize work to ensure all review documents are completed within the set timelines.
• Collaborate with Medical Administration and the Quality Department to ensure efficient completion of records reviews.
• Review prior discharge files for completeness and accuracy of medical records.
• Follow up on incomplete documents by contacting concerned physicians (consultants, specialists, residents).
• Coordinate in-service meetings to educate medical staff on proper documentation procedures and report any incorrect or missing documents to the concerned physician and/or HOD for correction.
• Participate actively in Quality meetings/reviews to ensure adherence to established guidelines.
• Prepare and present monthly reports in Quality Meetings and Surveys.
• Conduct regular meetings with physicians identified to have deficient medical files for educational purposes.
• Orient newly hired physicians on related departmental issues, including VIDA System, Approvals, and Claims.
• Ensure the representation of clinical pathways in all file compartments.
• Comply with standards set by JCIA and CBAHI.
• Follow and enforce the medical records department policies and procedures among staff.
• Report any violations of Medical Records Documentation (MRD) and Policies and Procedures (P&P) to the Medical Coordinator.
• Adhere to safety, security, and infection control measures.
• Participate in hospital educational activities.
• Lead person-centered care initiatives undertaken by HMG.
• Enhance patient experience with compassion, respect, and dignity.
• Perform other duties as assigned within one's knowledge, skills, and abilities.

Education / Professional Qualification

• Bachelor’s Degree
• Professional qualification in Nursing or Medicine and Surgery preferred

Experience

• Preferably four (4) years of experience in a medical records environment.

Professional Licensing / Certification / Training

• Saudi Council certification

Skills

Good communication skills, data gathering & assessment, patient service, data management & record keeping, process management.