Overview

The Health Information Management Clerk ensures that all chart requests are processed. Scanned medical records must be process within 24 hrs. Emphasis is placed on ensuring that the medical records are completed within the time frame as specified by the medical staff rules, and regulations.

Responsibilities

• Responsible for filing all medical records. Sort and file all assigned charts and loose materials daily.
• Files all reports in the appropriate location in the chart (i.e. operative, discharge summary, consultations, etc.)
• Responds to inquires for medical records.
• Retrieves all internal chart requests within 48 hrs.
• Stat requests for the continuity of patients’ care within 15 minutes.
• Requests for Patient information externally, within 5-7 business days.
  • (Please Refer to the Copying Medical Records Policy)
• Properly locates, and accounts for the patient’s medical records when requested. Adds pertinent test and lab work to charts requested if not available in the chart.
• Search Master Patient Index located in the Meditech (EMR system) for verification of date of service, type of service, and all other pertinent information when needed.
• Add location of a requested chart in the Locator Desktop in the Meditech System.
• Collect, sort, collate all Inpatient, Clinical, Ambulatory Surgery, and Emergency Room records to be copied/scanned/indexed.
• Reconcile 100% of all discharges daily against Discharge Census Lists.
• Assemble and organize all Inpatient, Ambulatory Surgery and Emergency room records using established department policies and procedures.
• Carefully analyze medical records of inpatient and outpatients for accuracy, timeliness and completeness as stated in JCAHO Standards RC.01.01.01, and RC.01.03.01.
• Performs continuous quality improvement functions on assigned primary numbers such as correcting misfiles, sign in charts that have been returned in the locator desktop in the Meditech System, and keeping files neat and accessible at all times.
• Answer, forward and reply to telephone inquiries using department policies to assure patient confidentiality and privacy is maintained.
• Release information to authorized parties using established policies and procedures to adhere to Federal, State and Regulatory requirements. Observes confidentiality and safeguards all patient-related information.
  • (Please refer to Copying Medical Records Policy)
• Communicates regularly with the Assistant Director regarding any problems, issues or concerns and any missing records (via e-mail or pager.)
• Adhere to departmental policies and procedures regarding tardiness, schedule breaks, lunch time, coverage, cell phone use and works with others to insure department operations are maintained.
• Reports their productivity statistics(via e-mail) to the HIM Assistant Director at the end of their shift
• Performs other duties as required.

Qualifications

Education:

• High school diploma or GED required.
• College experience required.

Experience:

• Must have at least one year of Medical Records, or other health related field experience.

Knowledge and Skills:

• Able to communicate in English both verbally, and in writing.
• Effective communication, and interpersonal skills required. 
• Computer literacy required with previous experience with PC Windows applications.
• Experience with Microsoft Office applications required.
• Proficiency in basic data entry skills.
• Accurate numeric filling experience required.
• Must be able to type 30 words per minute accurately.
• Must possess good organization skills, and the ability to work independently as well as with a team.
• Must be able to work with minimal supervision.

Physical Requirements:

• Involves standing, walking, sitting, talking, hearing and bending.
• Heavy lifting and long periods of standing is necessary. 

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions without compromising patient care.

The statements herein are intended to describe the general nature and level of work being performed by employees, and are not to be construed as an exhaustive list of responsibilities, duties, and skills required of personnel so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of Interfaith Medical Center.

Interfaith Medical Center is an equal opportunity employer, it is our policy to provide equal opportunity to all employees and applicants for employment without regard to race, color, religion, national origin, marital status, military status, age, gender, sexual orientation, disability or handicap or other characteristics protected by applicable federal, state, or local laws.