Health Information Specialist

Midwest Spine & Brain Institute LLC; Stillwater (MN); On-site; USD 25,000 - 32,000; Full time

Job summary

Midwest Spine & Brain Institute, LLC is seeking a Health Information Specialist/Medical Legal Specialist to manage medical records, imaging, and medical-legal documentation, ensuring HIPAA compliance and data integrity. This role serves as a critical link between clinical staff, patients, and outside care systems.

Responsibilities include handling surgery charts, imaging management, legal documentation requests, and tracking systems while maintaining strict confidentiality and data accuracy in a

Qualifications

• Requires at least two years of experience in health information management, medical records, or related healthcare operations.
• Knowledge of HIPAA requirements and patient confidentiality.
• Proficiency with computers, office equipment, and Microsoft Office applications.

Responsibilities

• File, locate, retrieve, index, scan, upload, and route medical records and related documentation.
• Complete surgery chart preparation no more than two weeks prior to surgery.
• Manage imaging through PACS, Ambra, Epic/EMI, and Medicom; obtain records from outside facilities as needed.
• Maintain accurate patient records and ensure proper indexing in the electronic health record.
• Support coding audits, chart reviews, and other departmental initiatives.

Skills

HIPAA compliance

Organizational skills

Communication skills

Customer service

Education

High School Diploma or GED

HIM certification (preferred)

Tools

NextGen

Epic

PACS

Ambra

Microsoft Office

Job description

Job Details: Job Location: CBO - Stillwater, MN 55082, Position Type: Full Time, Salary Range: $18.50 - $23.50 Hourly, Travel Percentage: None, Job Shift: Day, Midwest Spine & Brain Institute, LLC is seeking a detail-oriented and organized Health Information Specialist/Medical Legal Specialist to join our healthcare team. In this role, you will be responsible for the management, retrieval, preparation, and maintenance of medical records, imaging, and medical-legal documentation. This position will support surgery chart preparation, medical record processing, imaging management, legal documentation requests, and related tracking systems while maintaining compliance with HIPAA and organizational policies. You will serve as a critical link between clinical staff, patients, and outside care systems by ensuring that all health information is accurate, up-to-date, and strictly confidential.

Essential Duties and Responsibilities

Health Information Management

• File, locate, retrieve, index, scan, upload, and route medical records and related documentation.
• Complete surgery chart preparation no more than two weeks prior to surgery.
• Review surgery schedules, patient notes, and surgery tickets to obtain required documentation, reports, and imaging.
• Manage imaging through applicable systems including PACS, Ambra, Epic/EMI, and Medicom.
• Obtain records and imaging from outside facilities as needed.
• Maintain accurate patient records and ensure documentation is properly indexed within the electronic health record.
• Merge duplicate patient accounts and maintain data integrity within practice management systems.
• Track documents requiring provider signatures and ensure timely completion.
• Support coding audits, chart reviews, and other departmental initiatives as assigned.

Medical Legal Responsibilities

• Maintain medical-legal tracking and billing systems with a high level of accuracy and attention to detail.
• Complete medical-legal forms and documentation including FMLA, disability, parking permits, Department of Natural Resources permits, Social Security Disability forms, Medical Source Statements and other forms accurately and within established timelines.
• Prepare narratives and associated documentation for legal and insurance requests.
• Schedule and coordinate video depositions, telephone conferences, and in-person meetings utilizing established department processes.
• Prepare records and supporting materials for depositions, conferences, and legal proceedings in advance of scheduled deadlines.
• Ensure completed forms are properly filed within the patient record.
• Completes documents and administrative tasks assigned by leadership or providers.

Communication and Customer Service

• Respond professionally to phone calls, emails, and medical records inquiries.
• Accurately document messages and route information according to established procedures.
• Assist patients, providers, attorneys, external facilities, and vendors with record-related requests.
• Return calls and follow up on outstanding requests within established timelines.
• Maintain positive and effective working relationships with internal and external customers.

Compliance and Quality

• Maintain strict confidentiality of PHI and e-PHI.
• Adhere to HIPAA regulations and organizational policies regarding record retention, destruction, release of information, and medical-legal documentation.
• Review work for completeness and accuracy.
• Identify and resolve documentation discrepancies promptly.Maintain organized systems for records, imaging, forms, and outstanding requests.

Teamwork and Professionalism

• Manage multiple priorities while meeting established deadlines.
• Work independently with minimal supervision.
• Assist team members and support department goals as needed.
• Demonstrate professionalism, accountability, dependability, and adaptability in a fast-paced healthcare environment.

Participate in process improvement initiatives that enhance efficiency, quality, and patient satisfaction.

Qualifications: Qualifications

Required

• High School Diploma or GED.
• Minimum two years of experience in Health Information Management, medical records, medical office operations, billing, coding, or related healthcare experience.
• Knowledge of medical records filing systems and HIPAA requirements.
• Proficiency with computers, office equipment, and Microsoft Office applications.
• Strong organizational, communication, and customer service skills.
• Ability to maintain confidentiality and manage sensitive information.

Preferred

• HIM certification or related degree.
• Experience with NextGen, Epic, PACS, or similar healthcare information systems.
• Experience with medical-legal documentation and records management.

Core Competencies

• Technology Proficiency
• Time Management
• Critical Thinking and Problem Solving
• Written and Verbal Communication
• Service Orientation
• Attention to Detail
• Adaptability and Flexibility
• Dependability and Accountability
• Integrity and Professionalism
• Teamwork and Cooperation

Physical Requirements

• Prolonged sitting and standing.
• Frequent bending, stooping, and reaching.
• Manual dexterity and eye-hand coordination.
• Ability to safely lift up to 25 pounds.