Medical Records Clerk

Job Summary: Ensure that a medical record is maintained on every patient admitted to the hospital and to make sure standards for the medical record are met for the hospital, accrediting agencies, and third party payers.

QUALIFICATIONS:

1. High school diploma required, Associates degree preferred.

2. A minimum of 2 years secretarial/administrative experience in a comparable setting.

3. Experienced with EMR systems is required. Strong computer knowledge and skills is required.

4. Excellent customer service, verbal and written communication skills required.

5. Ability to work well with others to meet goals and deadlines.

6. Must be able to work flexibly as priorities change.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Core Competencies

Responsible for accurately logging and tracking patients charts once received into department and/or being checked out to other departments or individuals.

Assemble and audit charts upon discharge and according to the Order of Chart

Accurately enters into Avatar in a timely manner as defined by department policies and procedures:

Requests for information.

All disclosures of information.

Monies received for copies of medical records.

Daily discharge census

Processes charts after discharge with the following procedures:

Receive final summaries and log date into system when complete

Mail or fax out discharge summaries according to the authorization filled out at time of discharge.

Make copies of medical information for disclosure and sending out while checking for proper consent per knowledge of hospital, state and federal laws regarding confidentiality.

Pick up daily dictation log from transcription and enter dates dictated into discharge summary tracking log.

Responds to unit calls for assistance with charts, i.e., filing and preparation of discharged charts, picks up discharge chart from unit daily.

Handles all departmental mail including forwarding mail to discharged patients.

Professionally answers telephone calls and responds to customers requests.

Maintains proper inventory of department supplies and notifies supervisor to reorder as necessary.

Alphabetize and file documentation into the charts.

Responsible for the handling of charts for the following:

Copying charts for retroactive review for insurance companies

Pulling charts for periodic audits

Retrieving and returning inactive medical records to storage area on 3rd floor

Scan charts into the EMR system.

Performs various department related duties as assigned by Director in order to contribute to the efficient operation of the hospital and ensure quality of care.