Medical Chart Retrieval & Abstraction Specialist

Job Summary

• The Medical Chart Retrieval & Abstraction Specialist is responsible for obtaining medical records from healthcare providers and reviewing clinical documentation to identify, extract, and accurately document required patient information.
• This is a functional healthcare operations role requiring strong knowledge of medical terminology, medical records, chart review, data abstraction, and provider follow-up.

Key Responsibilities

• Retrieve medical records from hospitals, physician offices, clinics, and other healthcare organizations.
• Submit medical-record requests through electronic portals, fax, phone, mail, and other approved channels.
• Follow up with provider offices and medical-record departments on outstanding requests.
• Track record requests, status, receipt dates, and outstanding documentation.
• Review retrieved medical records for completeness, accuracy, and relevance.
• Perform medical chart abstraction based on established project guidelines and client requirements.
• Identify and extract information such as diagnoses, procedures, medications, laboratory results, treatments, encounters, and medical history.
• Review physician notes, discharge summaries, operative reports, laboratory reports, and other clinical documentation.
• Enter abstracted information accurately into healthcare databases, EMR/EHR systems, or designated data-collection platforms.
• Identify missing, inconsistent, or incomplete documentation and initiate appropriate follow-up.
• Conduct quality checks to ensure accuracy and completeness of retrieved and abstracted information.
• Maintain accurate documentation and records of all retrieval and abstraction activities.
• Meet established productivity, accuracy, quality, and turnaround-time requirements.
• Maintain patient confidentiality and comply with HIPAA and applicable privacy requirements.
• Collaborate with internal healthcare operations, quality, coding, clinical, and medical-records teams as required.

Required Qualifications

• Experience in medical records, chart retrieval, chart review, medical abstraction, or healthcare operations.
• Working knowledge of medical terminology and clinical documentation.
• Experience working with EMR/EHR systems or electronic medical-record platforms.
• Strong data-entry and documentation skills.
• Ability to interpret and extract information from medical records accurately.
• Strong attention to detail and organizational skills.
• Ability to communicate and follow up effectively with healthcare providers.
• Understanding of HIPAA and patient privacy requirements.
• Ability to work independently while meeting productivity and quality targets.