1. Job Purpose To lead and manage the Medical Records Department (MRD), ensuring accurate, complete, secure, and timely management of patient health records across the hospital. The role is responsible for medical records governance, documentation compliance, legal and statutory requirements, digitization initiatives, record retrieval, data quality, and adherence to NABH/JCI standards while supporting clinical, operational, insurance, and medico-legal functions.

2. Key Accountabilities

A. Medical Records Operations Management

- Oversee end-to-end management of inpatient, outpatient, emergency, daycare, and procedural medical records.
- Ensure accurate collection, verification, indexing, storage, retrieval, tracking, and archiving of records.
- Monitor record movement across departments and maintain complete traceability.
- Establish and monitor MRD operational standards and service levels.

Key Deliverables
- Timely record availability
- Record retrieval efficiency
- Zero record loss incidents
- Department productivity metrics

B. Clinical Documentation Compliance
- Ensure completeness and accuracy of clinical documentation including:

- Admission records

- Progress notes

- Consent forms

- Operative notes

- Anaesthesia records

- Discharge summaries

- Death summaries
- Conduct regular documentation audits.
- Coordinate deficiency management with consultants, RMOs, nursing, and clinical departments.
- Ensure timely closure of documentation deficiencies.

Key Deliverables
- Documentation completeness score
- Discharge summary compliance
- Documentation deficiency closure rate
- Clinical audit scores

C. Medical Records Governance & Confidentiality
- Establish robust policies for record management and health information governance.
- Ensure confidentiality and privacy of patient information.
- Manage authorized access and release of medical information.
- Ensure adherence to hospital policies and legal requirements concerning medical records.

Key Deliverables
- Information security compliance
- Confidentiality breach prevention
- Record access control compliance

D. NABH, JCI & Quality Compliance
- Ensure compliance with NABH, JCI, and other accreditation standards related to documentation and medical records.
- Participate in quality improvement initiatives.




- Support internal and external audits.
- Monitor implementation of corrective and preventive actions.

Key Deliverables
- Audit compliance scores
- Accreditation readiness
- CAPA closure compliance

E. Medico-Legal Records Management
- Manage medico-legal case (MLC) documentation and record retention.
- Coordinate with legal, risk management, and clinical teams for medico-legal requirements.
- Ensure availability of records for court cases, legal notices, insurance investigations, and regulatory audits.
- Maintain strict documentation and chain-of-custody protocols.

Key Deliverables
- MLC documentation accuracy
- Legal record retrieval TAT
- Compliance with retention requirements

F. Record Digitization & EMR Management
- Lead digitization and electronic medical record (EMR) initiatives.
- Ensure productive scanning, indexing, and quality verification of records.
- Collaborate with IT and clinical teams on EMR workflows.
- Monitor data integrity and record accessibility within the HIS/EMR platform.

Key Deliverables
- Digital record completeness
- Scanning quality compliance
- EMR adoption support

G. Insurance, TPA & Corporate Support
- Support insurance, TPA, corporate, and revenue cycle teams with medical documentation.
- Ensure timely availability of records for claim processing and audits.
- Coordinate resolution of documentation-related claim queries.

Key Deliverables
- Insurance record TAT
- Reduction in claim rejections due to documentation gaps
- Corporate audit support

H. Data Management & Reporting
- Maintain medical records statistics and performance dashboards.

- Monitor indicators such as

- Documentation completeness

- Deficiency rates

- Record retrieval TAT

- Scanning productivity

- Archival compliance
- Present periodic reports to management.

Key Deliverables
- Monthly MRD dashboard
- Compliance reports
- Management information reports

I. Team Leadership & Development
- Lead, mentor,



and supervise MRD executives, record technicians, and documentation staff.
- Establish staffing plans, KPIs, and performance goals.
- Conduct training programs on documentation standards, confidentiality, and accreditation requirements.
- Drive continuous process improvement initiatives.

Key Deliverables
- Team productivity
- Staff competency compliance
- Employee engagement

3. Competencies A. Core Values

- Patient First
- Excellence
- Accountability
- Respect
- Teamwork
- Integrity

B. Functional Competencies

Technical Competencies

- Health Information Management
- Medical Records Administration
- Clinical Documentation Auditing
- ICD Coding Awareness
- Medico-Legal Documentation
- NABH/JCI Standards
- Medical Terminology
- Record Retention Management
- Data Quality Management
- HIS/EMR Systems

Behavioral Competencies
- Leadership & Team Management
- Attention to Detail
- Stakeholder Management
- Analytical Thinking
- Problem Solving
- Communication Skills
- Process Improvement
- Decision Making

4. Educational Qualification

Essential

- Bachelor's Degree in Health Information Management (HIM), Medical Records Science, Life Sciences, Healthcare Administration, Nursing, Pharmacy, or Allied Health Sciences

Preferred
- Master's Degree in Hospital Administration (MHA)
- MBA Healthcare Management
- Certification in Medical Records Management
- Certification in Health Information Management (HIM)
- NABH Internal Assessor Certification

5. Relevant Experience

Essential

- 6-10 years of experience in Medical Records Department (MRD), Health Information Management, or Clinical Documentation Management.
- Minimum 3 years in supervisory or managerial capacity.

Preferred
- Experience in NABH-accredited multi-speciality hospitals.
- Exposure to JCI standards.
- Experience managing EMR and digitization projects.
- Experience handling medico-legal records and insurance documentation.

Ideal Profile A seasoned healthcare professional with strong expertise in health information management, medical documentation governance, accreditation standards, and digital records management, capable of driving hospital-wide documentation excellence and regulatory compliance in a 300+ bed tertiary care multi-speciality hospital.

📌 Manager MRD (Mumbai)
🏢 Sir Hn Reliance Foundation Hospital
📍 Mumbai