Job Title : Medical Records Clerk

Location : Williamsburg, VA 23188

Initial Duration : 3 months with possible extension

Shift :

8HR Monday -Friday 8 : 30am to 4 : 30pm

Job Description :

The Medical Records Specialist is responsible for qualitative workup of all medical records to include assignment of deficiencies, abstracting information for clinical indices, and preparation of chart for billing within set timelines.

Maintains medical record integrity through filing, assembling, analysis and retrieving of confidential patient records in compliance with established patient confidentiality policies, regulations standards.

May also be responsible for assigning ICD-10-PCS diagnostic and procedural codes to patient accounts codes and abstracts hospital medical records for maintenance of disease indices, internal and external reporting, research, compliance with federal, state, and other regulatory agencies, and for billing and reimbursement.

Essential functions :

Prepares and assembles medical records. Organizes and analyzes medical records for accuracy and completeness.

Establishes and maintains chart control, access and storage relating to the custody of chart and documents in accordance with established policies, procedures, and regulations.

Receives requests for information from medical records of patients in person, by mail, fax, from such sources as physicians, patients, lawyers, insurance companies, copy services, or health and welfare agencies.

Logs in and out all incoming request for release of information identifying the date received, mailed, and released information.

Assures authorization are properly executed when responding to requests for medical information.

Manages provided transcription services. Searches and prints dictated reports from computerized transcription system.

Ensures files are stored in the designated area according to storage procedures. Pulls charts as requested for audits, peer review, readmissions, HBIPS processing and routes to appropriate area or department.

Processes reports for delivery of records for use in answering correspondence.

Compares signatures and forwards standard letters to requesting parties, following established policies and procedures on the release of medical information.

Performs quantitative and qualitative analysis of discharge records, assigns physician / clinician deficiencies, and monitors completion of those deficiencies.

Abstracts clinical information to maintain indices within specified time frames as required.

Identifies records for quality review monitoring or audits according to specified criteria and assists in retrieving and compiling data as requested.

Files pertinent clinical data in the appropriate chart, sets up and breaks down of discharge charts. Purges and inventories medical records for off-site storage.

Communicates with transcriptionist or transcription vendor to resolve issues / errors regarding reports.

Maintains Master Patient Index of all clients admitted into the facility.

Prints and delivers medical records forms to patient units. Picks up discharge records from patient units.

May perform coding functions such as assigning appropriate codes using International Classification of Disease system (ICD-10) and / or Current Procedural Terminology (CPT) for diagnosis, procedures, and services.

Complies with organizational policies, procedures, performance improvement initiatives and maintains regulatory and industry standards.

Maintains regular and reliable attendance.

Accepts responsibility for professional growth and development of self and attends all mandatory facility in-services and staff development activities as scheduled.

Maintains professionalism and confidentiality of facility employees and patients.

Performs other duties as assigned.

Education / experience / skill requirements :

High school diploma or equivalent required.

A minimum of one year experience in Medical Records in psychiatric setting required.

Prior experience with HCS and as an abstractor in a health information management or related health care field is preferred.

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Last updated : 2024-05-21