MEDICAL RECORDS CLERK

Position Title:

Medical Records Clerk Department:

Medical Records Supervisor's Title:

Rev Cycle Manager I.

Position Summary:

Under immediate supervision, maintains patient files and statistics; responds to requests for medical records; performs clerical duties. II.

Principal Functions and Responsibilities:

A. Maintains established department policies and procedures, objectives, quality improvement and safety programs, environmental and infection control standards. B. Delivers and retrieves patient charts from in-house clinics and practitioners. C. Establishes and maintains inpatient and outpatient files and records on an ongoing basis. D. Performs discharge analysis of inpatient/outpatient and Same Day Surgery charts. Notes deficiencies in the content of charts. E. Responsible for weekly updating and dissemination of the Deficiency List (documenting deficiencies in patient chart content) to physicians and allied health professionals responsible for providing the missing chart content. F. Answers telephone and gives routine information. Under the direction of the Medical Records Director, releases information to patients, physicians, attorneys, other hospitals and medical facilities, insurance companies, using the telephone, fax, US mail or delivery service, as is deemed appropriate. Acts as Department Receptionist. G. Maintains patient confidence by keeping patient records information confidential. H. Retrieves old medical record numbers for microfilmed MPI cards, when required. I. Under the direction of the Medical Records Director, pulls records for off site scanning on a regular basis. J. Checks permanent files, on a regular basis, for misfiles to ensure accurate filing. K. Scans documents into the electronic medical record. L. Will perform chart audits for accurate charges. M. Ensure charges are added/removed to patient accounts in a timely manner. N. Assists in care and maintenance of Department equipment and supplies. O. Participates in educational programs and in-services. P. Attends meetings as required. Q. The employee will maintain positive and effective relations with co-workers, other departments, patients and visitors. R. Performs other related duties as assigned or requested. III.

Position Qualifications/Requirement:

Minimum Education:

High school diploma or equivalent.

Preferred Education:

Health Information Management Preferred Minimum Experience and Skills:

At least one year of experience working as a Medical Records Clerk in a Medical Records Department in an acute care hospital. Must have computer and people skills.

Physical Requirement:

Walking, lifting, reaching, hand-eye coordination, speaking.

Certification, Registration or Licensure:

None required

Working Conditions:

Primarily works in an office setting, Potential exposure to patient elements in general. Blood borne pathogens - some exposure to blood on reports.