Medical Records Clerk

 
Position Summary:

The primary purpose of your position is to maintain, organize and evaluate medical records in accordance with federal and state guidelines as well as in accordance with our established policies and procedures to ensure that a complete medical records program is maintained. The medical records clerk also maintains a system of records concerning patient diagnosis, treatment, admissions, discharges and transfers related to daily patient changes. In addition, the position maintains constant communication with various Departmental staff to gather information.

Responsibilities: 

• · Maintains a case load of 70-80 to ensure medical records are in accordance with federal and state guidelines as well as in accordance with our established policies and procedures

  · Receives and follows work schedule/instructions from supervisor and as outlined in our established policies and procedures

  · Knowledge of chart control, access and storage in accordance with established policies

  · Knowledge of medical records regulations and release of protected health information

  · Prepares copy of records when presented with properly completed medical release forms

  · Ensures confidentiality of all medical records information and completes forms for release of information.

  · Ensures all medical records filing is up to date.

  · Reviews records for completeness before filing.

  · Verifies that health record information is filed accurately and appropriately to resident’s charts, overflow records, and discharge records.

  · Protects medical record information from loss, defacing, or destruction per record retention requirements.

  · Maintains a good working rapport with inter-department personnel, as well as other departments within the facility, to ensure that medical records can be properly maintained.

  · Monitors physician visitation based on required visitation timeframes. Interacts physician/or physician staff to verify visitation occurs appropriately.

  · Verifies proper management and transfer of health record information as requested.

  · Identifies incomplete documentation (audits) and reports to individuals responsible for completion. Ensures that corrections are made of identified findings.

  · Maintains bound Master Admission & Discharge Register for admissions and discharges to and from the facility.

  · Verifies information on master resident face sheet is completed

  · Maintains computer database for admissions, physician orders, care plans, and MDS information.

  · Completes special audits as requested.

  · Mails documents to the facilities physicians as required for appropriate signatures and timely Implements systems developed for advising disciplines of documentation to be completed or corrected.

  · Manages timeframes for returned signed documentation.

Benefits: 

• Up to $26 per hour 

• Health Benefits – Medical, dental, and vision coverages with company paying majority of costs for Medical HMO (with buy up plan options available) 

• 401(k) with company match (company match begins after 1 year of service) 

• Company paid Life and disability insurance 

• Paid Time Off (Vacation, Sick, Holiday) 

Equal Opportunity Employer