Medical Records Clerk

Job Title: Medical Records Clerk

Job Summary: As a Medical Records Clerk, you will play a crucial role in maintaining accurate and organized medical records for our healthcare facility. You will be responsible for ensuring the confidentiality, integrity, and accessibility of patient information in accordance with legal requirements and company policies. This position requires meticulous attention to detail, strong organizational skills, and the ability to work effectively in a fast-paced medical environment.

Responsibilities:

1. Record Management:

• Create and maintain electronic health records (EHR) and/or physical charts for patients.
• Ensure all records are complete, accurate, and up-to-date, including patient demographics, medical history, test results, diagnoses, treatments, and other pertinent information.
• Review records for completeness, accuracy, and compliance with regulations.

2. Data Entry and Retrieval:

• Enter new patient information into the system accurately and efficiently.
• Retrieve and release medical records to authorized personnel and patients as per established protocols.
• Respond to requests for medical records in a timely manner, ensuring proper authorization and documentation.

3. Confidentiality and Compliance:

• Maintain strict confidentiality of all patient information in compliance with HIPAA regulations.
• Ensure adherence to company policies, procedures, and legal requirements related to medical records management.
• Assist in audits and quality assurance activities related to medical records.

4. Filing and Organization:

• File and organize physical records according to established procedures.
• Scan and upload paper records into the electronic system for easy access and storage.
• Monitor and manage the organization of medical records storage areas.

5. Communication:

• Collaborate with healthcare professionals to obtain missing information or clarify documentation.
• Communicate effectively with patients, staff, and external parties regarding medical record requests and inquiries.
• Provide support and training to colleagues on medical records procedures and systems.

6. Quality Control:

• Perform regular checks to ensure the accuracy and completeness of medical records.
• Identify and correct errors or inconsistencies in records.
• Assist in maintaining the integrity of the electronic medical records system.

Qualifications:

• High school diploma or equivalent (Associate's degree in Health Information Management is a plus).
• Proven experience as a Medical Records Clerk or similar role in a healthcare setting.
• Knowledge of medical terminology, procedures, and coding (ICD-10, CPT) preferred.
• Familiarity with electronic medical records (EMR) systems and software.
• Strong attention to detail and accuracy in data entry and record keeping.
• Excellent organizational and time-management skills.
• Ability to handle sensitive and confidential information with professionalism.
• Good communication and interpersonal skills.
• Knowledge of HIPAA regulations and other legal requirements related to medical records.
• Ability to work independently and collaboratively in a team environment.

Working Conditions:

• Typically works in an office setting within a healthcare facility.
• May require occasional lifting or moving of boxes/files.
• Potential for extended periods of sitting and computer use.
• Interaction with patients and healthcare professionals.