Medical Records Assistant/Clerk (Part-Time)
Ayers Health and Rehab
Trenton, FL
JOB DESCRIPTION
Job Title: Medical Records Clerk
Department: Medical Records
Reports to: Medical Records Director
General Purpose:
This position assists the Medical Records Director with maintaining medical records for the facility in accordance with policies and procedures established for the medical record keeping, under the guidance of the Health Information Consultant.
Qualifications:
- High School Graduate or Equivalent, prior Health Information or medical experience preferred.
- Able to understand the Medical Record Systems, including filing and electronic medical records.
- Must have ability to follow oral and written instructions.
- Possess personal attributes to include professionalism, neatness, accuracy.
- Must present a professional appearance.
- Must be able to cooperate and work well with fellow employees.
- Must be knowledgeable of computer systems, system applications, and other office equipment.
- Must be able to meet all local health regulations and pass pre/post-employment physical exam, if required. This requirement also includes drug screening, criminal background investigation, and reference inquiry.
- Must attend in-service/education programs as required to learn new procedures and develop skills to meet regulatory compliance.
- Must agree not to disclose resident protected health information and report suspected or known violations of such to the Administrator.
Duties and Responsibilities:
- Assist Medical Records Director to assure that the admission summary (face sheet) is complete.
- Assist Medical Records Director to determine whether additional transfer data is needed and request from transferring facility if needed. Follow-up to assure receipt.
- Check the record quantitatively on admission and periodically to assure completeness, accuracy and internal consistency.
- Communicate with and assist the medical staff and allied health personnel in updating records.
- Maintain the flow of the reports to the records.
- Check the discharge documentation quantitatively to assure completeness, accuracy, and internal consistency.
- Obtain complete and accurate records within thirty (30) days of discharge or in accordance with state regulations.
- Assure face sheet discharge information is correct.
- Assure all required reports are in the record.
- Follow appropriate procedures for closing a record permanently incomplete, if required.
- Maintain overflow records.
- Maintain a tracking system for physician visits and the authentication of orders.
- Maintain accurate and timely Medicare certifications, as required.
- Provide information, when requested, to those involved in research projects and studies with the approval of center administrator.
- Maintain the numerical filing system for records.
- Maintain the unit numbering system for record identification.
- Maintain the necessary sign-out and follow-up controls of records.
- Maintain and control release of information to authorized persons.
- Type and/or transcribe reports of correspondence according to the needs of the HIM department.
- Assist with preparing charts for legal requests, audits, etc. as assigned.
- Attend facility meetings as required.
- All other duties as assigned.
Physical and Sensory Requirements: Walking, sitting, standing, reaching, stooping, bending, lifting, grasping, pushing and pulling, and fine-hand coordination. Ability to hear and respond to overhead pages. Ability to communicate with residents, families, personnel, vendors, and consultants. Ability to apply training and in-service education provided. Must present a neat, clean, professional appearance and demonstrate a positive approach with employees and residents.
Every effort has been made to make your job description as complete as possible. However, it in no way states or implies that these are the only duties you will be required to perform. The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements that may be inherent in the position. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.
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