Medical Records Clerk

Description

Job title

Medical Records Clerk

Reports to

Business Office Manager

FLSA Status

Non-Exempt

Position Summary

The Medical Records Clerk completes analysis and filing of all medical records and reports in a timely and accurate manner. Compiles statistical information as requested for the Cherry County Hospital and Clinic.   

Duties and Responsibilities

Regular responsibilities include but are not limited to the following:

• Maintains records on all patients
• Compiles statistical reports as instructed
• Prepares Death, Tissue, and Blood Reports
• Completes birth certificates with the aid of the computer or typewriter
• Retrieves records for physicians and other hospital staff
• Reviews medical records for accuracy and completeness of entries and follows through on corrections or additions.
• Assembles contents of medical records in the preestablished order for permanent filing
• Reviews inpatient and emergency room records to ensure the required reports and signatures are contained in the record
• Notes deficiencies to be completed by physician and other professional staff
• Answers telephone and gives routine information
• Completes records and logs for emergency room patients
• Assists with duplication of records for release of information
• Maintains master patient index file
• Files loose reports on permanent record
• Updates deceased files
• Maintains outpatient observation and surgery log
• Maintains patient and department confidentiality
• Types medical staff minutes
• Maintains medical staff appointment files
• Pre-certification of patients as needed
• Backs up the transcriptionist as needed
• Answers the telephone for the front desk if needed
• Attends workshops and hospital in-service as requested
• Helps prepare for clinic and hospital staff meetings
• Makes copies as needed of medical records for patients and other entities
• Supplies information with regard to subpoenas if the supervisor is absent 
• Ensures the confidentiality of patients’ medical, personal, and financial records is maintained
• Knowledgeable of and committed to practicing Corporate Compliance policies and procedures
• Complies with Cherry County Hospital personnel policies
• Performs other duties as assigned by the supervisor

Skills and Abilities Required

• Numerical and clerical ability to make statistical computations
• Typing ability is essential
• Good English and spelling skills
• Good communication skills
• Ability to exercise independent judgement 
• A preference for adjusting and adapting to the ever-changing rules and regulations of the Hospital and Federal Government
• Ability to treat records without emotional involvement
• Ability to work closely and cooperatively with department personnel, administration, physicians, business office, nursing, x-ray, physical therapy, laboratory, respiratory therapy, quality assurance, infection control, and various other departments, and the public
• Must be able to keep hospital and patient information confidential
• Must be knowledgeable of state and federal confidentiality laws, including but not limited to HIPAA, and be familiar with and follow all policies, procedures and instructions regarding the privacy and security of protected health information applicable to the position

Physical Demands and Working Conditions

• Requires sitting for long periods of time, standing, and bending when filing and lifting stacks of records
• Environment requires working in close proximity with others in a clean favorable area
• Unless otherwise stated, time required is full-time days
• Must be willing to work weekends, overtime, and holidays, if scheduled or called back

Direct reports

This position has no direct reports.

Requirements

 Minimum Job Requirements

• High School graduate preferred
• Typing skills, English, and math
• Prior experience or education relating to office skills preferred