The primary purpose of the Medical Records Clerk position is to establish and maintain organized medical records and files assuring compliance with state/federal standards. At times, this position may provide clinical and administrative support to the nursing department. The position is also responsible to assist nursing with entering medications & documentation within the facility's electronic health record.
ESSENTIAL JOB FUNCTIONS include the following. Other duties may be assigned. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
- Maintain organized medical records and files assuring compliance with state/federal standards
- Continuously reviews open records for accuracy and completeness
- Contacts physicians and other professional as necessary to maintain complete records
- Assures accuracy/completeness of closed records
- Maintains support record systems
- Maintains accuracy/completeness of electronic health records (EHR) within facility's closed based software application.
- Monitors and processes physician certification forms for Medicare
- Locates, signs out, and delivers medical records requested by various departments in accordance with facility and state specific regulations
- Establishes and maintains medical and form inventories
- Protects medical information to be within HIPAA compliance. Complies with all applicable federal standards in regards to access control, disaster recovery, document destruction, business continuity, incident response, and risk management
- Prepares and types correspondence, reports, and other documentation as directed by supervisor.
- Prepares and/or submits forms and documentation to and/or from physicians as necessary
- Reports any issues or problems that may arise to the Director of Nursing and/or Administrator
- Complies with state, federal, and all other applicable health care and safety standards
- Assists families and other visitors as needed
- Attends/completes required in-services and other required meetings
- Depending on certification/license, may be asked to assist with care needs for residents under the direction of the Administrator and/or Director of Nursing.
- Performs other duties as directed
EDUCATION and EXPERIENCE an equivalent combination of education, training and experience will be considered.
- Required: High School diploma or equivalent
- Preferred: Minimum of one (1) year experience in medical records; or an equivalent combination of education and experience
- Preferred: Previous long-term care experience preferred
SUPERVISORY REQUIREMENTS of this position are generally as follows:
- This position does not regularly require supervisory responsibility.
- There will be some supervisory responsibilities when other employees are tasked to assist with medical record filing.
KNOWLEDGE, SKILLS and ABILITIES which may be representative but not all inclusive of those commonly associated with this position.
- Language Ability - Reads and interprets documents. Ability to write simple reports and correspondence
- Written Communication - Writes clearly and informatively; able to read and interpret written
- Verbal Communication - Talks to others to convey information effectively
- English Language - Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar
- Clerical - Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, and other office procedures and terminology.
- Active Listening - Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times
- Quality Management - Demonstrates accuracy and thoroughness
- Organizational Support - Follows policies and procedures; completes tasks correctly and on time
- Adaptability - Adapts to changes in the work environment; changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events
- Planning/Organizing - Prioritizes and plans work activities; advises for additional resources
- Attendance/Punctuality - Ensures work responsibilities are covered when absent; arrives at meetings and appointments on time
- Dependability - Completes tasks on time or notifies appropriate person with an alternate plan
- Professionalism - Treats others with respect and consideration regardless of their status or position; accepts responsibility for own actions.
COMPUTER SKILLS/EQUIPMENT USED TO PERFORM THE JOB which may be representative but not all inclusive of those commonly associated with this position.
- Desktop/Notebook computers
- MS Office (Word, Excel, PowerPoint, etc.)
PHYSICAL ABILITIES commonly associated with the performance of the functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is frequently required to talk or hear, stand, walk, sit, stoop, kneel or crouch, use hands to use hands to grasp, manipulate or feel objects and reach with hands and arms.
- The employee is occasionally required to taste or smell
- The employee must regularly lift and/or move up to 20 pounds and occasionally lift and/or move up to 50 pounds
- Specific vision abilities required by this job include close vision, distance vision, color discrimination, peripheral vision, depth perception, and the ability to adjust focus
Job Type: Full-time