Medical Records Officer For Home Care Organization

Job Summary

Key Responsibilities1. EMR Documentation Management

• Review patient records in the EMR system for completeness, accuracy, and timeliness
• Ensure all home care visits are properly documented, including:
• Nursing notes
• Vitals
• Care plans
• Medication records
• Identify missing, inconsistent, or delayed documentation and follow up with clinical staff
• Ensure proper use of addendums, late entries, and corrections (no overwriting of records)

2. Malaffi Compliance & Data Submission

• Ensure required patient data is accurately shared with Malaffi through the EMR system

3. Documentation Auditing

• Conduct regular audits (daily/weekly) of patient files
• Identify trends in documentation errors or non-compliance
• Prepare audit reports and share findings with management
• Support internal and external audits (DOH inspections)

4. Staff Support & Training

• Guide nurses and clinicians on proper documentation practices
• Provide training on EMR usage and documentation standards
• Educate staff on compliance requirements related to DOH and Malaffi

5. Policy & Compliance

• Ensure all documentation aligns with DOH regulations and company policies
• Assist in developing and updating documentation policies and procedures
• Maintain confidentiality and security of patient records at all times

Skills & Competencies

• Strong knowledge of EMR systems
• Familiarity with DOH regulations and Malaffi requirements
• High attention to detail and accuracy
• Strong organizational and auditing skills
• Good communication skills (to follow up with clinical staff)
• Ability to handle confidential information

Job Type: Full-time