Medical Records Clerk

Overview

We are looking to add a compassionate Medical Records Clerk to our amazing records department team!

Keystone Treatment Center is a 126 Bed Treatment Center providing services to adults on an inpatient basis. Keystone is located in Canton SD, just a short drive from Sioux Falls, SD.

PURPOSE STATEMENT:

Perform clerical duties associated with obtaining, completing and maintaining a patient medical records.

MEDICAL RECORDS SECRETARY

Distinguishing Characteristics:

This individual assists with maintaining medical record integrity throughout the patient’s treatment stay and beyond, in accordance with Federal, State, and CARF guidelines. This position requires an understanding of the facility’s treatment program and philosophy. This individual must work flexible hours, interact with patients and family members, provide support to medical and clinical staff, and communicate verbally and electronically with various outside entities to include, but not limited to, referral sources, medical facilities, attorneys, parole officers, law enforcement, insurance companies, AND employers.

Responsible To: Medical Records Supervisor

Supervision Is Approved Through:

• Facility monitoring activities.
• Direct observation.
• Staff meetings/in-service’s.
• Management meetings.
• Individual meetings as needed.
• Disciplinary and grievance procedures.
• Annual performance appraisal.

Qualifications:

• Education/
  
  Experience:
  
  High school diploma or equivalent required with college or technical school preferred. Three or more years’ experience in a secretarial role and management of medical records.
• Skill Requirements:
  Ability to perform job duties independently, communicating both verbally and electronically with male and female patients, medical and clinical staff, and various outside entities as described above. Working knowledge of medical and pharmaceutical terminology with an ability to transcribe dictation. Proficient in Microsoft Office (specifically Word, Excel, and Outlook).

Position Supervised: Medical Records Supervisor.

Working Environment:

Office space is provided by the facility with materials, equipment, and supplies necessary to perform assigned tasks.

Physical/Emotional Demands and

Working Conditions:

Must display coping skills to perform a variety of job duties with an ability to prioritize requests from staff and outside entities. Critical thinking and problem‑solving skills are necessary skill to perform in this position. Work is mostly sedentary with minimal walking, standing, lifting, stooping, reaching, and bending. Occasional physical exertion (lifting 30‑50 pounds) is required. Must read, write, speak, and understand English.

Risk of exposure to infectious and contagious/blood‑borne disease. Exposure to varying and unpredictable situations (i.e., patient behavior). Subject to work schedule and shift changes.

Position Classification: Non Exempt OSHA Classification: 2

• Process requests for medical records according to policy and procedure.
• Create appropriate releases of information/consent forms and obtain patient signature.
• Process newly admitted patients, working in Med Host and Best Notes.
• Identify inconsistencies, errors, and missing information within Best Notes that could compromise patient care.
• Process requests from staff for correspondence with outside entities.
• Release weekly summaries for each patient to outside entities.
• Transcribe dictation and upload to Best Notes.
• Assist patients and Medical Director with completion of patient FMLA and ST Disability forms and submit to insurance companies and/or employers.
• Process Millon Tests.
• Exhibit clear, concise verbal and written communication as observed by direct observation.
• Demonstrate telephone skills (answering, taking messages, placing on hold, and transferring calls)
• Correspond verbally and electronically with staff, referral sources, attorneys, parole officers, medical facilities, insurance companies, employers, and law enforcement.
• Check email and Teams multiple times throughout the day, responding as necessary to requests.
• Input data into Best Notes, Med Host, and Medical Records Log.
• Scan paper medical records into Best Notes.
• Deliver…