Medical Records Clerk

To maintain resident medical records and health information systems in accordance with current federal and state guidelines and established policies and procedures and ensure resident health information is protected and not disclosed unless by permission or with established policies and procedures.

Essential duties and responsibilities include the following:

*Note: Other duties may be assigned

·         Retrieves resident records (manually/electronically).  Delivers as necessary.

·         Files information such as nursing notes, assessments, progress notes, lab reports, x-ray results, correspondence, etc., either manually or electronically into resident charts.

·         Collects, assembles, checks, and files resident charts.

·         Ensures incomplete records/charts are returned to appropriate department or personnel for corrections.

·         Ensures resident records are properly completed, assembled, coded, etc., before filing.

·         Extracts information from records for insurance companies, Medicare, Medicaid, VA, long-term care insurance, etc., in accordance to established policies and procedures and privacy rules.

·         Picks up and delivers medical records to designated areas as necessary.

·         Answers telephone calls in regards to inquiries about medical records.  Prepares written correspondence as necessary.

·         Files active and inactive records as per established policies.

·         Completes portion of death certificates as indicated.

·         Maintains logs of specific items as per established policies and procedures.

·         Maintains requests for medical records forms and completes as necessary.

Supervisory Responsibilities

This job has no supervisory responsibilities.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skills and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

High school diploma or equivalent required. Minimum of 2 years’ administrative experience and/or a degree or certification in health information management or medical coding preferred, but not required. Working knowledge of medical terminology, anatomy and physiology, coding, and other aspects of health information preferred, but not required.

Language Skills
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, procedure manuals, and federal and state regulations. Ability to write routine reports and correspondence.  Ability to speak effectively before groups of customers or employees of organization.

Mathematical Skills

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area circumference, and volume.  Ability to apply concepts of basic algebra and geometry.

Reasoning Ability
Ability to apply common sense understanding to carry out instructions furnished in written, oral or diagram form. Ability to deal with problems involving several concrete variables in standardized situations. 

Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential 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 regularly required to walk; use hands to finger, handle or feel; reach with hands and arms; talk or hear; and taste or smell.  The employee frequently is required to stand.  The employee is occasionally required to sit; climb or balance; and stoop, kneel or crouch.  The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision and depth perception.

Work Environment  
The work environment characteristics described here are representative of those an employee encounters while performing the essential 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 exposed to wet and/or humid conditions; moving mechanical parts, extreme cold; or extreme heat.  The noise level in the work environment is usually moderate, but occasionally may be exposed to loud noise.

Privacy Understanding  
It is the position of Brethren Retirement Community that all of its employees have the potential to encounter both written and oral information of a private nature.  It is understood that as an employee the highest standards of discretion must be observed.  Under no circumstances will resident information be shared with any other person except for authorized person providing for the care of the individual(s).

Employee completed annual compliance training & exhibits behavior as set forth by the code of conduct in the performance of their duties.

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