Medical Records Clerk
The primary purpose of your position is to to maintain resident medical records and health information systems in accordance with current federal and state guidelines as well as in accordance with our Facility’s established privacy policies and procedures.
Receive and follow work schedule and instructions from your supervisor and as outlined in our established policies and procedures.
Assist in organizing, planning, and directing the medical records department in accordance with established policies and procedures.
Assist the Facility medical personnel, as required.
Develop and maintain a good working rapport with other departments within the Facility, to assure that medical records can be properly maintained.
Retrieve resident records (manually and electronically).
Deliver as necessary.
Files information such as nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.
Collect, assemble, check and file resident charts, as required.
Ensure incomplete records and charts are returned to appropriate departments or personnel for correction.
Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.
Ensure all residents records are coded, stored, completed correctly, and maintained in a confidential manner.
Responsible for closure of discharged resident records.
Prepare record for closure by organizing the record in an orderly fashion, bind the record, and review record for completeness.
Works with nursing department for closure.
Tracks and monitors release of discharge resident records and thinned records to interdepartmental personnel and physicians.
Complete thinning or resident records in a timely manner to maintain appropriate forms on the record and delete those that are not needed on the active file.
Maintain thinned material from resident records in a neat and orderly manner.
Review thinned material for completeness.
Storage of thinned information in the station file cabinet on medical records in a neat and orderly fashion.
Ensure physician orders are signed within a timely fashion.
Maintain Credentialing and Privileging records for physicians.
Ensure Death Certificates are included in closed charts and notify nursing if missing.
Establish a procedure to ensure resident charts and records do not leave the medical records room except as authorized in our policies and procedures.
Maintain a record of authorized information released from charts and records, i.e., type information, name of recipient, date, department, etc.
Abstract information from records as authorized and required for insurance companies, Medicare, Medicaid, VA, etc. in accordance with current Privacy Rules.
Index medical records as directed by the medical records and health information consultant.
Maintain various registries as directed including register for admission and discharge of residents.
Assist the Quality Assessment and Assurance Coordinator in developing, implementing and maintaining an ongoing quality assurance program for medical records.
Assist the Quality Assessment and Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies.
Participate in QA/QI meetings on a monthly and/or quarterly basis.
Collect charts, assemble them in proper order, and inspect them for completion.
Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas, as necessary.
Must adhere to all HIPAA requirements.
Experience and Education
Must posses a GED degree
A working knowledge of medical terminology, anatomy, and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required.
On-the-job training provided in medical record and health information system procedures
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