Job description
POSITION SUMMARY
The Medical Records Clerk is responsible and accountable for the maintenance of health records. In this capacity, the employee organizes and maintains a system of health files and logs concerning patient diagnosis, treatment, admissions, discharges and daily patient census changes. The employee is expected to exercise good judgment, maintain confidentiality and function independently.
JOB RELATIONSHIPS
REPORTS TO: Health Services Administrator
SUPERVISES: None exercised in this position
INTER-RELATES WITH: Medical and nursing staff, patients, security staff at all levels, administrative and support staff, consulting physicians, community medical facilities and regional team members as necessary.
DUTIES/RESPONSIBILITIES
Job Requirements:
PREFERRED EDUCATION/EXPERIENCE/LICENSURE REQUIREMENTS
EDUCATION:
High School Diploma or GED equivalent
EXPERIENCE:
Minimum of one (1) year medical records experience
CERTIFICATION:
Current CPR Certification
LICENSURE:
Not applicable
OTHER KNOWLEDGE/
SKILLS/ABILITIES:
15922
The Medical Records Clerk is responsible and accountable for the maintenance of health records. In this capacity, the employee organizes and maintains a system of health files and logs concerning patient diagnosis, treatment, admissions, discharges and daily patient census changes. The employee is expected to exercise good judgment, maintain confidentiality and function independently.
JOB RELATIONSHIPS
REPORTS TO: Health Services Administrator
SUPERVISES: None exercised in this position
INTER-RELATES WITH: Medical and nursing staff, patients, security staff at all levels, administrative and support staff, consulting physicians, community medical facilities and regional team members as necessary.
DUTIES/RESPONSIBILITIES
- Maintains a system and updates facility health status requirements for inmate physical, laboratory, PPD, etc.
- Files loose documentation generated from inside and outside institutions such as laboratory reports, radiology results, completed consultation reports, progress notes, etc.
- Ensures confidentiality of all medical records information.
- Retrieves medical charts for all healthcare staff or clinics as requested
- Validates and ensures that forms for the release of information are current, accurate and complete as defined by HIPAA.
- Retrieves, delivers, and files health records daily as needed.
- Files daily all currently used medical records to ensure ease of availability.
- Checks to ensure that health files are complete (contains all necessary documents) with all loose notes properly secured, and in the correct sections.
- Ensures that the guidelines for hardcopy clinical entries are met at all times (use of hardcopy when Electronic Health Records is not available).
- Releases information at the direction of the Medical Director or Health Services Administrator.
- Refer to supervisor any requests of a questionable nature.
- Ensure the security of all active and inactive medical records.
- Assists in preparing periodic statistical reports and other management information system requirements. Maintain logs for appropriate medical unit onsite staff.
- Answers telephone, relay messages and transfer calls as appropriate.
- Exercises professional telephone etiquette.
- Ensures that messages are complete (contain return number, correct spelling of names, and nature of the call)
- Performs clerical/technical duties.
- Prepares, types and distributes letters, reports and other correspondence.
- Maintains a roster of appointment book based on scheduled appointments for both on and off-site appointments.
- Orders, receives and maintains office supplies to include unit par-levels.
- Maintains cabinets and shelves used for supporting the health files.
- Understands and comply with all state, facility and company policies, procedures and protocols as related to the medical records department.
- Meets timelines as related to death records, released inmates' health records and case management and departmental productivity guidelines.
- Scan medical records into the Electronic Health Record.
- Enter medical records into the database.
- Overlook new medical records archive systems/rack replacement.
- Upon receiving the necessary training and/or instruction, performs other related duties as required or assigned
Job Requirements:
PREFERRED EDUCATION/EXPERIENCE/LICENSURE REQUIREMENTS
EDUCATION:
High School Diploma or GED equivalent
EXPERIENCE:
Minimum of one (1) year medical records experience
CERTIFICATION:
Current CPR Certification
LICENSURE:
Not applicable
OTHER KNOWLEDGE/
SKILLS/ABILITIES:
- Ability to maintain regular and reliable attendance
- Strong interpersonal skills.
- Strong verbal and written communication skills.
- Knowledge of the Problem Oriented Medical Record System.
- Demonstrated experience meeting multiple deadlines. Must ensure documents are ready for review well in advance of any deadline.
- Ability to competently manage multiple priorities simultaneously.
- Ability to work in a stressful environment.
- Must be a "team-player" as this position requires daily coordination with other coworkers
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