Health Records & Information Officer

Overview

Job Summary The Health Records and Information Officer is responsible for managing patient records and hospital data systems to ensure accurate, confidential, and timely information flow across departments. The role supports clinical services, billing, and reporting functions by maintaining high data quality standards. In a specialized eye hospital setting, the officer handles outpatient records, surgical registers, optical data, outreach information, and Ministry of Health (MOH) reporting, serving as a key contributor to hospital performance tracking and decision-making. Key Duties and Responsibilities Health Records Management Register new patients and retrieve records for returning patients across outpatient, theatre, optical, and outreach services Create, organize, and maintain both physical and electronic medical records in accordance with MOH standards Ensure confidentiality, integrity, and security of patient information in line with the Data Protection Act (2019) Implement and maintain efficient filing systems (e.g., serial, terminal digit, or EMR-based indexing) for timely retrieval Track missing files and conduct routine audits to ensure completeness and accuracy of records Data Management and Reporting Accurately enter patient data into EMR/HMIS systems, including demographics, diagnoses, procedures, and outcomes Compile daily workload summaries such as outpatient attendance, surgical volumes, optical services, and laboratory tests Prepare and submit monthly MOH reports including MOH 204A/B, MOH 711, MOH 705, and surgical summaries Generate internal dashboards and reports to support management decision-making (e.g., patient wait times, surgical outcomes, revenue tracking) Validate data received from various departments and identify discrepancies for timely correction Billing and Claims Support Code diagnoses and procedures using ICD-10 and relevant SHA/SHIF procedure codes Collaborate with the claims team to ensure alignment between clinical documentation and billed services Generate patient statements and discharge summaries in a timely and accurate manner Monitoring, Evaluation, and Quality Assurance Maintain disease-specific and surgical registries, including cataract, glaucoma, diabetic retinopathy, and pediatric cases Support clinical audits by extracting and analyzing patient data and outcomes Track outreach program data and ensure linkage of outreach patients to hospital services Participate in Data Quality Audits (DQA) and implement corrective actions as required Train and support clinical staff on proper documentation standards to improve overall data quality Administrative Responsibilities Oversee records storage, archiving, and disposal in accordance with established retention policies Supervise records clerks and provide mentorship to interns Monitor functionality of EMR/HMIS systems and escalate technical issues to relevant teams Requirements Qualifications and Experience Diploma or Degree in Health Records and Information Management from a recognized institution such as KMTC Registered with the Association of Medical Records Officers Kenya (AMRO-K) or a relevant professional body Valid practicing license Minimum of 2 years’ experience in a healthcare setting, with demonstrated use of EMR systems Proficiency in Microsoft Excel and MOH reporting tools Experience working with at least one EMR/HMIS system Required Skills and Competencies High level of accuracy and attention to detail in data handling and record management Strong knowledge of MOH reporting requirements and ICD-10 coding standards Proficiency in Microsoft Office applications, particularly Excel (including pivot tables, charts, and basic formulas) Strong analytical skills with the ability to interpret and validate healthcare data Clear and effective written and verbal communication skills Strong interpersonal skills to coordinate with clinical and administrative teams Understanding of patient confidentiality, data protection, and ethical standards Ability to work under pressure and meet strict reporting deadlines, particularly during month-end periods Good organizational and time management skills Ability to train and support staff on documentation and data quality practices