Description

The Medical Records Clerk is responsible for retrieving and reconciling medical records and loose documentation from ancillary departments, nursing units and clinics. Other duties may include routine data entry, timely scanning and indexing of late loose documentation, assisting with release of information (ROI) requests, answering phones, and chart analysis of the patient record

Job Duties and Responsibilities

• Retrieves discharged medical records/reports/etc. departments throughout the hospital and clinics and reconciles them using ATHENA to ensure that all records are accounted for.
• Batches, labels and scans loose reports, late charts and/or late documentation to the medical record.
• Assists customers with ROI requests, ensuring the validity and authorization of the request, routing to HealthPort, and processing urgent requests on a limited basis
• Assist with the physician documentation process by monitoring the dictation system and printing history and physicals, immediate operative reports, operative reports, consultations and discharge summaries. Scans these required reports to the patient medical record.
• Processes facility specific HIM mail as applicable.
• May assist with physician questions related to the physician portal or other issues that may arise.
• Demonstrates the spirit of the philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment.
• Applies the principles and values of customer service and continuous quality improvement while performing day to day activities of the position.
• Maintains and protects confidentiality regarding all aspects of patient care, personnel and strategic issues. Adheres to Confidentiality Policy.
• Maintains positive working relationships and fosters cooperative work environment. Adheres to the hospital’s compliance program.
• Displays honesty and mutual respect when communicating with peers and other departments.
• Follows through on problems that may compromise effective job performance by using appropriate chain of command.
• Adheres to safety practices and meets requirements of National Patient Safety Goals.
• Performs other duties as assigned.

Qualifications

Education

• High School Diploma or GED; or equivalent combination of education and experience.

Certification, Licensure

• Non-applicable

Experience

• One (1) year related experience and/or training, preferably in a hospital setting. Medical record experience preferred.

Knowledge, Skills and Abilities

• Excellent organizational skills. Excellent writing and composition skills. Must type 50-60 wpm. Excellent computer, word processing, database, and credentialing software skills.