Medical Records Clerk

The Medical Records Clerk maintains medical records in accordance with federal and state guidelines, as well as in accordance with established policies and procedures, to assure that a complete medical records program is maintained.

The following is a general list of key job duties and responsibilities in your position. The list is not to be considered inclusive and you will be required to perform other duties/responsibilities as assigned by an authorized supervisor.

Comply with the Facility’s personnel, safety, and corporate policies and procedures.

Comply with the nursing department’s policies and procedures.

Report witnessed or reported allegations of resident abuse/neglect immediately to the Administrator, Director of Nursing or Unit Manager.

Treat residents, family members, visitors, and team members with respect and dignity.

Maintain the confidentiality of all resident and family information.

Report to work on time and as scheduled.

Maintain minutes of meetings/files as necessary.

Develop and maintain a good working rapport with all departments as well as residents and families.

Ensure notices of incomplete records/charts are given to department heads for correction.

Follow established policies and procedures for the medical records section.

Establish a procedure to ensure paper charts/records do not leave the section except as authorized in our policies and procedures. Maintain a record of authorized information requested from charts/records, i.e., type information, name of recipient, date, department, etc.

Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc. Collect paper records, assemble them in proper order, and inspect them for completion.

Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed. Assist with obtaining Medicare Certifications and Recertification’s timely.

Assist in admission, transfer and discharge procedures as necessary.

Answer telephone inquiries concerning medical records functions.

Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.) Assure that medical records taken from the department are signed out and signed in upon return.

Ensure Physicians’ orders, telephone orders and other records requiring signatures are received and filed. File active and inactive records in accordance with established policies.

Closes and files discharged resident medical charts. Review charts for deficient information and ensure compliance for correction of documentation.

Other related duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility. Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.

Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately.

Report equipment malfunctions or breakdowns to your supervisor as soon as possible.

Ensure supplies have been replenished in work areas as necessary.

Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of work day, etc.

Maintain confidentiality and security of all pertinent resident care information to assure resident rights are protected. Knock before entering a resident’s room.

Assure that resident rights are fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints, are followed.

Responsible for knowing relevant State and Federal laws and regulations;…