A Medical Records Clerk compiles, processes, and maintains medical records of hospital and clinic patients in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system.
Responsible for performing receptionist, clerical and transcription duties related to the manual and mechanical processing of physician orders on an assigned nursing unit. Responsible for the accurate collection of patient demographic and insurance information and computer data entry for patient registration for assigned unit. May be responsible for charge posting. Employee is subject to call back and overtime as required by the hospital.
ESSENTIAL JOB FUNCTIONS
Assembles patients' charts, records patient information on unit records and routes patient charges when applicable. Transcribes physician orders, completes related forms, schedules procedures via computer and/or manual process, adds forms related to procedures to chart and notifies licensed personnel. Answers telephone and appropriate pages and relays information to appropriate team manager and notifies physician of consults and schedules appointments for office visits. Acts as receptionist for the unit, provides information and assistance for all hospital personnel, physicians, patients, vendors, and the general public. Maintains charts, stamps and adds forms, posts lab, x-ray and other related reports; dismantles chart and collects all patient related forms necessary for discharge or transfer. Prepares and obtains unit supply orders as necessary. Recognizes the value of continued occupational growth and development. Responsible for ordering medications and services such as ambulance transport. May have charge posting capabilities and must enter patient charges with correct service date. Responsible for alerting the CPR team and 911 in the event of a code emergency. Accurately collects demographic and insurance information for computer data entry for patient registration for services. Must be able to handle multiple tasks in a fast paced environment without being easily distracted. Must be able to communicate with many different levels of hospital personnel, often handling communications about many different situations at once. Performs responsibilities as related to the safe disposal of hazardous pharmaceutical waste. Performs related responsibilities as required or directed.
JOB SPECIFICATIONS
EDUCATION:
Ability to read, write legibly, perform basic mathematical calculations as normally acquired through high school training or completion of GED program. Clerical training preferred, but not required. Knowledge of medical terminology and abbreviations is preferred.
LICENSURE, REGISTRATION, CERTIFICATION
Unit Secretary certification is encouraged. BLS certification is preferred.
EXPERIENCE
Clerical experience and knowledge of medical terminology preferred but not required. Knowledge of hospital and department policies, routines for tests and procedures, medical terminology, unit forms and record keeping, and ability to transcribe physician's orders as required through on the job training.
NONDISCRIMINATION NOTICE STATEMENT
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, ethnicity, disability, religion, national origin, gender, gender identity, gender expression, marital status, sexual orientation, age, protected veteran status, or any other characteristic protected by law.
