Medical Records & Compliance Specialist

Muir Wood Adolescent & Family Services is a residential treatment program designed specifically for teens ages 12-17 suffering from mental health and substance use conditions. The Muir Wood environment helps build strong peer relationships essential in early recovery, many of which blossom into enduring friendships. Our programs fill a crucial need by making mental healthcare available to the vast majority of families in need.

For more information on our programs, please visit our website: www.muirwoodteen.com

The Medical Records & Compliance Specialist is responsible for reviewing and auditing client records to ensure accuracy, compliance, and quality in the documentation of treatment and services. This role is essential in maintaining and preserving the clinical integrity of documentation and confidentiality of client information, and ensuring that employees follow policies and procedures of all regulatory bodies.

Essential Functions and Responsibilities:

Records Compliance:

• Conduct detailed reviews of client Medical Records and clinical documentation related to mental health and substance use disorders.
• Examine all documentation (assessments, screenings, treatment plans, progress notes, groups notes, discharge notes, and discharge summaries, etc.) to ensure all required components are present and completed within required timeframes.
• Ensure that client records comply with Community Care Licensing, Department of Health Care Services, The Joint Commission and HIPAA (Health Insurance Portability and Accountability Act).

Data Accuracy:

• Verify that all clinical information, including diagnoses, treatment plans, individual sessions, family sessions, group notes and other relevant information, are accurately recorded in the client record.
• Ensure that all entries are signed and that supervisor signature is present as required for non-licensed clinical staff

Medical Records Management:

• Respond to Medical Records requests from parents and outside entities, and ensure signed ROI is present and uploaded to client record.
• Communicate requests for information with Clinical Directors and treating clinicians to ensure no damage is imparted on the client and/or their families.
• Respond to subpoenas and court orders requesting client information under the direction of the Chief Compliance Officer.
• Preserve client confidentiality as required by HIPAA, federal/state laws and ethical standards.
• Prepare Medical Records for delivery when authorized

Auditing and Reporting:

• Prepare audit reports summarizing findings and any areas of concern or improvement needed.
• Forwards these findings weekly to the Chief Compliance Officer.
• Communicate audit results to relevant staff and management, facilitating corrective actions when necessary.

Training and Education:

• Collaborate with HR Director to ensure staff trainings and competencies in Relias are met within expected timeframe.
• Stay up-to-date with changes in regulations and industry standards to ensure the organization's practices remain current.

Confidentiality:

• Maintain strict confidentiality of the client records and sensitive information, adhering to all privacy and security policies.
• Additional duties as assigned by the Chief Compliance Officer.

• Bachelor's degree in healthcare administration or a related field.
• Knowledge of behavioral health treatment and documentation.
• Knowledge of Community Care Licensing, Department of Health Care Services and The Joint Commission requirements.
• Familiarity with relevant healthcare regulations and standards, including HIPAA.
• Strong attention to detail and analytical skills.
• Excellent communication and interpersonal skills.
• Prior experience in medical record auditing.

Benefits include:
Medical/Dental/Vision
Flexible Spending Accounts
401k
PTO/Sick

Pay is $65,000-$80,000 based on education and experience

Muir Wood Adolescent & Family Services provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.