Medical Records Clerk Job Opening

Purpose:

To maintain resident medical records and health information in accordance with current federal and state guidelines, as well as in accordance with our established privacy policies and procedures, to assure that a complete medical records program is maintained.

Essential Functions:

• Assist in organizing, planning and directing the medical records section in accordance with established policies and procedures.
• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
• Collect, assemble, check and file resident charts as required.
• Ensure incomplete records/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 the timely completion of medical records and perform and audit for accuracy and completeness prior to filing the record for microfilming.
• Establish a procedure to ensure charts/records do not leave the section except as authorized in facility policies and procedures.
• Maintain a record of authorized information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
• Extract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc. in accordance with current Privacy Rules.
• Maintain various registries as directed including register for admission and discharge of residents.
• Batch resident information into the computer and retrieve resident demographic information as instructed.
• Type reports for physicians as necessary.
• Collect charts, assemble them in proper order, and inspect them for completion.
• Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.)
• File active and inactive records in accordance with established policies.
• Supervise medical records department during the absence of the Medical Records Director.
• Maintain confidentiality of all pertinent resident care information to assure resident rights are protected.
• Performs other related assignments as required.

Work Schedule

• As assigned, including some week-ends, evenings and Holidays.

Working Conditions

• Works in well-lighted/ventilated areas.
• Most of the work is performed indoors
• Is subject to frequent interruptions.
• The noise level in the work environment is usually moderate.
• Is involved with residents, personnel, visitors, government agencies, etc., under all conditions and circumstances.
• Is subject to hostile and emotionally upset residents, family members, etc.
• Communicates with the medical staff, nursing staff, and other department supervisors.
• Works beyond normal duty hours, on weekends, and in other positions temporarily, when necessary.
• May be exposed to bodily fluids, infectious waste, diseases, conditions, etc., including the AIDS and hepatitis B viruses.

Physical Requirements

• While performing the duties of this job, the employee is occasionally required to stand; walk; use hands to finger, handle, or feel; implements or office equipment; reach with hands and arms; stoop, kneel, crouch, or crawl and talk or hear.
• Must be able to speak and write the English language in an understandable manner.
• Collect information through observation, listening, touching, and smelling.
• Must have auditory ability sufficient to monitor and assess
• Job requires regular sitting, standing, walking, stooping, bending, kneeling, crouching, reaching, pushing, pulling, twisting, writing, and carrying charts, etc.
• Must be able to move intermittently throughout the work day.
• Specific vision abilities required by this job include close, distance and color vision and the ability to adjust focus.
• Must be able to cope with the mental and emotional stress of the position.
• Must function independently, have flexibility, personal integrity, and the ability to work effectively with the residents, personnel, and support agencies.
• Must be in good general health and demonstrate emotional stability.
• Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and at times hostile people within the facility.
• May be required to lift, push, pull, and move equipment, supplies, etc., in excess of fifty (50) pounds.

Safety, Sanitation and Infection Controls

• Assure the assigned work areas are maintained in a clean, safe and sanitary manner.
• Assure that established infection control and universal precautions practices are observed.
• Report all hazardous conditions or equipment to your supervisor.
• Follow established safety policies and procedures.
• Dispose of refuse daily in accordance with established sanitation procedures.
• Keep work/assignment areas free of hazardous objects, unnecessary equipment, supplies, etc.
• Report any accident/incident to your supervisor no matter how minor.

Qualifications:

• Must possess, as a minimum, a high school diploma or GED
• Must be able to type a minimum of 45 words per minute, use dictation equipment, and have a working knowledge of medical terminology.
• On-the-job training provided in medical record and health information system procedures; ICD-9-CM coding experience preferred.
• Must be able to read, write, speak, and understand the English language.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, visitors and the general public.
• Must possess the ability to minimize waste of supplies, misuse of equipment, etc.
• Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices.
• Be able to follow written and oral instructions.
• Be knowledgeable in computers, data retrieval, input and output functions, etc.