Job Description

Key Activities:

Follow all relevant policies, processes, standard operating procedures, and instructions and ensure work is carried out in a controlled and consistent manner.

• Promote the implementation and adherence to relevant policies, processes, and operating procedures to others.

• Contribute to the identification of opportunities for continuous improvement of systems, processes, and practices, taking into account leading practices, improvement of department processes, cost reduction, and productivity improvement.

• Apply safety, quality, and environmental management policies, procedures, and controls to ensure safety, legislative compliance, delivery of high-quality service, and a responsible environmental attitude.

• Build high levels of trust and understanding with key internal and external stakeholders to promote full compliance with industry regulations and promote a broader understanding of Dallah Health’s interests and practices.

Perform daily checks to ensure that patient medical records are complete, accurate, and in compliance with hospital documentation standards.

-Identify deficiencies, incomplete documentation, or errors and communicate with relevant staff or departments to resolve them.

-Assist in tracking record completion and delinquency rates.

-Ensure that physical or electronic records are properly organized, indexed, and filed according to established procedures.

-Assist with chart assembly and document scanning if required by department workflows.

-Verify that records contain all necessary clinical documentation for accurate coding.

-Communicate with coding teams to clarify documentation details when needed.

Process requests for medical records or information release in compliance with privacy laws and hospital policies.

-Verify authorization and consent before releasing any patient information to internal or external parties.

-Maintain logs and documentation related to release information.

-Handle all patient information with strict confidentiality in accordance with MOH and hospital privacy requirements.

-Report any potential data breaches or unauthorized access to the HIM Operations Assistant Manager.

-Liaise with physicians, nurses, and other departments to resolve documentation or record-related queries.

-Support audits or surveys by preparing records and integrity reports as assigned.

-Suggest improvements to operational workflows, checklists, or filing processes to enhance HIM service delivery.

-Stay updated on changes in HIM standards, privacy laws, and hospital documentation policies.

Knowledge and Experience:

4–7 years of relevant HIM or medical records experience in a hospital setting.

-Familiarity with MOH standards, data privacy regulations, and CBAHI/JCI accreditation requirements.

Education and Certifications:

Bachelor’s degree in Health Information Management, Health Informatics, or a related field.

-Valid registration with the Saudi Commission for Health Specialties (SCFHS) if required

SKILLS

Strong knowledge of EMR configuration, documentation workflows, and clinical informatics principles.

-Sound understanding of coding and clinical documentation requirements.

-Effective communication skills to engage clinicians, IT, and administrative teams.

-Strong analytical skills for monitoring data quality and driving improvements.

-High level of integrity and respect for patient confidentiality.