What are the responsibilities and job description for the Medical Records Clerk position at Care New England?
Job Summary
Maintains all documentation of admission, service and discharge in patient medical records. Knowledgeable in all aspects of Agency policy and services.
Duties & Responsibilities
Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts the nation’s top specialty-trained doctors, hones renowned services and innovative programs, and engages in the important discussions people need to have about their health and end-of-life wishes. Care New England is helping to transform the future of health care, providing a leading voice in the ongoing effort to ensure the health of the individuals and communities we serve.
EEO Statements
Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.
EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status
Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.
Maintains all documentation of admission, service and discharge in patient medical records. Knowledgeable in all aspects of Agency policy and services.
Duties & Responsibilities
- Utilizes the Care New England Home Health standards of ACT as a basis for delivery of services.
- Processes and maintains records for patients who are admitted to service, including all documents to be placed in the medical record and discharge records.
- Responds to Quality Improvement requests for copies of medical records. Copies and/or faxes entire records or specific information requested, ensuring completeness of documents. Required to obtain off-site medical records when necessary.
- Processes paperwork in an orderly fashion upon receipt in Medical Records to ensure availability until filed.
- Completes admission and discharge medical records audits, using a checklist, per Agency policy.
- Coordinates with clinical staff, if necessary, to ensure required documentation is included and complete.
- Identifies and verifies patient name and ID number, ensures documents are complete with necessary signatures, and all entries and files are in record according to name/date format, according to Agency policy and procedure.
- Creates new records for patients when necessary.
- Ensures maintenance and confidentiality of medical records.
- Prints and/or mails 485’s, verbal orders, and tracks for timely signature and return.
- Documents tracking of number of days from admit to mailing of 485, delinquent staff and physicians.
- Implements a record control system that includes tracking of outgoing information, including charts pulled for audits and the like to ensure recovery of all information.
- Cross cover designated positions in Medical Records department and team secretaries as needed.
- High school diploma or equivalent required. Associate’s Degree in Secretarial Science or graduate of secretarial school program preferred.
- Two (2) years secretarial experience in a medical setting preferred.
- Demonstrated competency in office/clerical procedures, including typing, professional telephone skills, filing, photocopying and fax operations.
- Previous experience with PCs and knowledge of the Microsoft Office package, including Excel and Word, required; database knowledge preferred.
Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts the nation’s top specialty-trained doctors, hones renowned services and innovative programs, and engages in the important discussions people need to have about their health and end-of-life wishes. Care New England is helping to transform the future of health care, providing a leading voice in the ongoing effort to ensure the health of the individuals and communities we serve.
EEO Statements
Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.
EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status
Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.