OVERVIEW:

The Medical Records Clerk is responsible for directing, planning, coordinating, and administering the facility’s medical records program.

RESPONSIBILITIES:

·Ensures that medical records are complete, accurate, and conform and state boards of health standards

·Reports any variations noted and new regulations or requirements, in accordance with standard medical records practices

·Trains staff in coding, indexing, filing, preparing and displaying of information, transcription, medical terminology nomenclature and classification of diseases, and computer services including such related matters as hospital organization, goals, policies and practices, and medical records ethics, laws and regulations

·Supervises and monitors the release of confidential information in accordance with rules and regulations

·Compiles statistical information and registers pertaining to the medical records department, ancillary services, and other statistical information as assigned or requested

·Supervises and coordinates the preparation of statistical information for medical staff, medical staff committees, accreditation agencies, state agencies, and the administration

·Participates and represents the medical records department in various facility committees and medical staff committees as assigned

·Appears in court when subpoenaed to testify about the authentication of medical records

·Abides by the state peer review statute

·Monitors communicable diseases and reports to the state BOH through the infection control officer

·Provides diagnosis codes to the fiscal services department on a timely basis to expedite filing of insurance claims for patient services rendered as required by hospital and external agencies

·Assist in the Quality Assurance and Performance Improvement (QAPI) process

QUALIFICATIONS:

EDUCATION / EXPERIENCE:

·Two years medical records experience in a physician's office or other health care facility

·Thorough knowledge of accepted medical-records practices including medical records ethics, classification, and nomenclature

·Knowledge of accreditation standards and state health regulations

·Ability to interpret medical records department policies and procedures and to apply them in specific situations

·Thorough knowledge of federal and state regulations, laws, and utilization review committee planning, organization, and management

·Knowledge of medical staff bylaws, rules, and regulations, and the state peer review statute

·High school graduate or equivalent

·ART (accredited records technician) or RRA (registered records administrator) designation preferred

SUPERVISORY RESPONSIBILITIES:

·This position has no supervisory responsibilities

WORK ENVIRONMENT:

·This job operates in a professional office environment

·This role routinely uses standard office equipment

PHYSICAL REQUIREMENTS:

·The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

·While performing the duties of this job, the employee is required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; talk or hear.

·The employee must occasionally lift or move office products and supplies, up to 20 pounds.

TRAVEL:

·There is no travel expected for this position