Medical Records Clerk

General Purpose

The primary purpose of your job position is to maintain resident Medical Records and health information systems in accordance with current federal and state guidelines as well as in accordance with our facility?s established privacy policies and procedures.

Essential Duties

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Administrative Functions

• Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.
• Assist in organizing, planning and directing the Medical Records department in accordance with established policies and procedures.
• Assist the Medical Records/Health Information Consultant as required.
• Maintain minutes of meetings. File as necessary.
• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that Medical Records can be properly maintained.
• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
• Retrieve resident records (manually/electronically). Deliver as necessary.
• Files information such as nurses? notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.
• Collect, assemble, check and file resident charts as required.
• Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.
• Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.
• Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.
• Establish a procedure to ensure resident charts/records do not leave the Medical Records room except as authorized in our policies and procedures.
• Maintain a record of authorized information released 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. in accordance with current Privacy Rules.
• Index Medical Records as directed by the Medical Records/health information consultant.
• Maintain various registries as directed including register for admission and discharge of residents.
• Transcribe and type reports for physicians as necessary.
• Collect charts, assemble them in proper order, and inspect them for completion.
• Pick up and deliver resident Medical Records from wards, nurses? stations, and other designated areas as necessary.
• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.
• Answer telephone inquiries concerning Medical Records functions. Prepare written correspondence as necessary.
• 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 to the department.
• File active and inactive records in accordance with established policies.
• Index Medical Records as directed.
• Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.
• Agree not to disclose resident?s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
• Report any known or suspected unauthorized attempt to access facility?s information system.
• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of this position.

Committee Functions

• Perform secretarial duties for committees of the facility as directed.
• Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.

Personnel Functions

• Report known or suspected incidents of fraud to the Administrator
• Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines. Staff Development
• Attend and participate in mandatory facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, etc.).
• Attend and participate in workshops, seminars, etc., as approved.

Safety and Sanitation

• Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately. Equipment and Supply Functions
• 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 workday, etc.

Budget and Planning Functions

• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.