What are the responsibilities and job description for the Medical Records Clerk position at North Texas Medical Center?
JOB SUMMARY
Reviews medical records after discharge for completeness in compliance with the hospital’s bylaws, CIHQ standards, federal and state requirements. Interview parents of newborns in order to obtain and prepare for an accurate and complete birth certificate. Ensures that all medical record requests are processed timely and accurately. Responds to request for medical information by performing duties in accordance with established hospital and departmental policy and state and federal laws.
SUMMARY OF ESSENTIAL JOB FUNCTIONS
- Collects all discharged patient medical records from the patient care units on a daily basis and check-in the record in the computer system.
- Account for all records and notify the Director of any not received.
- Assembles discharged patient medical records according to forms placement guidelines. Forwards all assembled medical records to coding, after checking records out in the computer system.
- Audit and analyzes medical records of discharged patients for completeness and accuracy according to department and hospital policy and procedures.
- Enters deficiencies into computer, check record out, and forward to appropriate physician for completion.
- Reroute records by removing completed deficiencies from the computer and routing record to next physician for completion or main file.
- Obtain information pertinent to child/parent from the obstetric and pediatric records for completion of birth certificates. Must process birth certificates with in 36 hours of birth.
- Secures all necessary signatures for proper filing and have filed with the state within 5 days of birth.
- Pull requested records for surgeries, reviews, committees, and audits.
- Sign out records from the department using the computer so record can be located.
- Responsible for coordinating the release of medical information to all requestors. Verifies authorizations in accordance with hospital policy and state and federal laws.
- Sort and deliver departmental mail to appropriate personnel.
BASIC SKILLS
- Basic computer skills
EDUCATION AND WORK EXPERIENCE REQUIRED
- High School graduate preferred.
- 1 or more years of previous similar hospital experience.
- Knowledge of CIHQ standards and state regulations for acute care facilities preferred
- Ability to work with physicians in a collaborative manner.
LANGUAGE SKILLS
- Ability to read and communicate effectively in English.
- Additional languages preferred
PHYSICAL REQUIREMENTS
- There can be prolong sitting and standing with this job. There is moderate kneeling, crouching, stooping, and crawling while retrieving and filing records. There is moderate reaching, pulling and pushing with arms and hands.
- Must be able to lift at least 50 pounds occasionally.
Experience
Required- 1 year(s): Similar Hospital Experience
Education
Preferred- High School or better
