Introduction
The Hospital Medical Records Staff (Staf Perekaman Medis) is a vital member of our clinical documentation team, responsible for ensuring that patient information is accurately captured, securely stored, and readily available for clinical, billing, and regulatory purposes. Working in a fast‑paced, technology‑enabled environment, you will collaborate closely with physicians, nurses, billing specialists, and the casemix department to maintain the highest standards of data integrity and confidentiality. This role offers an excellent opportunity for a recent graduate or early‑career professional to develop specialized coding expertise while contributing to the overall quality of patient care.
Responsibilities
- Collect, verify, and enter patient medical records into the hospital’s electronic health record (EHR) system.
- Apply appropriate ICD‑10‑CM, CPT, and DRG coding standards to ensure accurate clinical documentation and reimbursement.
- Collaborate with the casemix team to analyze case complexity, support quality reporting, and improve hospital performance metrics.
- Conduct regular audits of medical charts to identify discrepancies, missing information, or coding errors, and implement corrective actions.
- Maintain strict adherence to privacy regulations (HIPAA, local health data laws) and the hospital’s ethical code when handling patient information.
- Prepare and submit timely reports for internal management, external auditors, and health insurance providers.
- Assist in the training of new staff and provide ongoing education to clinical teams about proper documentation practices.
- Support the billing department by providing accurate coding data that facilitates prompt and correct claim submissions.
- Participate in multidisciplinary meetings to discuss documentation improvements, patient safety initiatives, and process efficiencies.
- Work independently or as part of a team to meet daily workload targets while maintaining high accuracy rates.
Requirements
- Minimum education: Diploma (D3) in Medical Records or related health information management field; a Bachelor’s degree (S1) is preferred.
- Age not exceeding 28 years at the time of application.
- Valid and current Surat Tanda Registrasi (STR) for medical records personnel.
- Proficiency in medical coding, including ICD‑10‑CM, CPT, and DRG systems.
- Prior experience in a casemix or health information department is highly desirable.
- At least one year of professional experience in a hospital setting is preferred.
- Demonstrated personal attributes: responsibility, honesty, meticulous attention to detail, discipline, initiative, and strong communication skills.
- Ability to work both independently and collaboratively within multidisciplinary teams.
- Commitment to maintaining confidentiality of all medical records in accordance with ethical standards and legal requirements.
- Basic computer literacy, familiarity with EHR software, and a willingness to adopt new health‑IT tools.
Benefits
- Competitive salary package with performance‑based incentives.
- Comprehensive health, dental, and vision insurance for employees and eligible dependents.
- Paid annual leave, sick leave, and statutory holidays (Monday‑Saturday work schedule, 08:00‑17:00).
- Professional development allowance for certifications, workshops, and conferences related to health information management.
- Access to on‑site wellness programs, including fitness facilities and mental‑health support.
- Opportunities for career advancement within the hospital’s growing health‑information department.
- Transportation stipend or parking reimbursement.
About Company
Our hospital is a leading tertiary care institution committed to delivering compassionate, high‑quality medical services to the community. With a network of specialized clinics, cutting‑edge technology, and a team of over 1,000 dedicated healthcare professionals, we strive to set the benchmark for clinical excellence and patient safety. We foster a collaborative culture that values continuous learning, innovation, and ethical practice. By joining our team, you become part of a mission‑driven organization that places patient well‑being at the core of every operation, while supporting the professional growth of its staff.
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