Job Title: Medical Records Clerk
Job Summary: Responsible for assembling patient information into designated medical charts/records in an accurate and complete manner.
Job Responsibilities/Tasks:
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Communicates, when needed, with physicians and other health care professionals to clarify medical record information (diagnoses, treatments, etc.) and to obtain any additional information required.
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Ensures that all necessary information is housed in patients’ medical records (manual or computer file) and done so in the practice preferred style (chronological).
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Organizes patients’ health information including symptoms, medical history, examination results, lab tests, ancillary reports (x-ray, ultrasound, etc.), diagnoses, and treatment plans.
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Provides patient charts/documentation requested for legal use while adhering to patient consent/confidentiality protocols.
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Reviews medical records to ensure all relevant forms are completed, properly identified, and signed by necessary parties.
Required Skills/Abilities:
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Ability to competently utilize all relevant practice management software and tools
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Ability to effectively analyze medical records for completeness and accuracy with close attention to detail
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Proficient in handling a mass amount of information in an efficient and organized manner
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Strong knowledge of medical terminology
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Strong knowledge of legal and ethical requirements relevant to the protection and distribution of patient information
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Skilled in inputting patient information into the preferred medical record system while meeting practice standards
Education:
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High School Diploma or Equivalent
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Associate’s Degree from community/junior college
Experience:
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Preferred 2 years of medical records clerk/health information technician experience in a healthcare environment
Disclaimer: This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.
Work Environment: Position is in a well-lighted medical office environment. Occasional evening and weekend work.
Physical Requirements: Must possess the physical and mental abilities to perform the tasks normally associated with an Executive Assistants such as sitting for 80 percent of the day; manual dexterity to operate office machines including computer and calculator; stooping, bending to handle files and supplies; and mobility to complete errands or deliveries, lifting up to 20 lbs. Stress can be triggered by multiple staff demands and deadlines.
