Medical Records Quality Assurance Assistant

Job Description:
The Medical Records Quality Assurance (QA) Assistant plays a vital role in ensuring the integrity, accuracy, and completeness of patient medical records. This position involves meticulous review and analysis of medical documentation to ensure compliance with institutional policies and healthcare regulations. The QA Assistant works closely with physicians, nurses, and other healthcare professionals to validate clinical entries, identify discrepancies, and ensure the timely completion and correction of medical records. In addition, the role involves compiling detailed summaries of documentation errors and supporting the implementation of quality improvement initiatives related to health information management.

Key Responsibilities:

Conduct comprehensive audits of medical records to assess accuracy, consistency, and completeness.

Identify documentation gaps and discrepancies in accordance with regulatory and institutional standards.

Collaborate with attending physicians, nurses, and other medical staff to facilitate timely and accurate record completion.

Prepare and submit reports summarizing identified errors, patterns, and recommendations for improvement.

Ensure adherence to documentation standards including familiarity with ICD-10 coding guidelines.

Support the continuous improvement of quality assurance processes within the Medical Records Department.

Qualifications:

Bachelor’s Degree in a healthcare-related field (e.g., Nursing, Medical Technology, Health Information Management, or equivalent).

Working knowledge or basic familiarity with ICD-10 coding and medical terminology.

Strong attention to detail, analytical skills, and commitment to upholding data integrity.

Excellent communication and coordination skills.

Open to full-time employment.