Medical Records Clerk

Summary

The Medical Records Clerk will ensure the day-to-day accuracy and completeness of resident medical records.  These functions to include the completion of audits and updating files as new medical provider orders are submitted.  These tasks involve the filing and sorting of documents, and developing or improving of processes and workflows to ensure accuracy of those records. Area of assignment could include, but may not be limited to, nursing, administration, housekeeping, or maintenance.

The Rewards!

We believe that positive resident experiences begin with positive employee experiences. That’s why we’re proud to offer:

• Comprehensive benefits package to include:
  • Health, Vision, & Dental Insurance
  • 401(k) Retirement Plan with Company Match
  • Company Paid Life Insurance
• Paid Time Off (PTO) 
• Paid Holidays
• Employee celebrations
• Professional recognition

Job Summary

To perform this job successfully, an individual must be able to perform each essential duty and responsibility satisfactorily. For a complete listing of essential duties, responsibilities, and physical demands, please contact our Human Resources department.

Essential Duties & Responsibilities

To perform this job successfully, an individual must be able to perform each essential duty and responsibility satisfactorily.

• Complete audits as directed using established guidelines and procedures.
• Report circumstances to Administrator and/or supervisor when scheduled audits cannot be completed timely.
• Submits report of problems identified to the Administrator and supervisor of each department and follows up on all audit reports until corrections are completed.
• Correctly transcribes doctors orders, medical terminology, medical and other related abbreviations, metric and English measurements, etc.
• Maintains, updates, files, and stores all Medical Records as required.
• Mail/deliver forms to physicians for completion to the extent permitted by regulations.
• Answers correspondence in a timely manner regarding release of information from medical records.
• Audits records in preparation for the release of records to outside parties.
• Audits medical record information relating to Medicare and Utilization Review requirements.
• Knowledge of medical terminology.
• Knowledge of office procedures and practices.
• Help create an atmosphere of optimism, warmth, and interest in resident’s personal and health care needs.
• Communicate with co-workers at all levels to adequately meet the needs of residents.
• Participate in facility committees and audits, as needed.
• Maintain confidentiality of all resident information and facility business.
• Report to supervisor all complaints and grievances made by residents, families, visiting individuals, agencies, etc.
• Attend work and report in a timely manner for scheduled shifts.
• Notify supervisor of pending absence or tardiness within the time frame described in the personnel handbook.
• Other duties as assigned.

 Qualifications

The requirements listed below are representative of the knowledge, skills, and/or abilities required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Communicate effectively and appropriately with residents, families, and members of the health care team.
• Recognize and respond to the needs of the residents.
• Communicate a sense of caring, concern and dignity for residents.
• Maintain a positive, upbeat, and encouraging attitude toward the residents.
• Effectively manage time to perform the essential functions of the job.
• Function in the health care team as a resident advocate.
• Must not pose a direct threat to the safety or health of self or others.
• Make prompt and accurate judgments with regard to Medical Records Clerk duties.
• Observe and assess at the Medical Records Clerk level the physical, psycho-social, and safety needs of residents.
• Proficient in the use of all Microsoft Office products and familiarity and basic working knowledge of facility specific information systems that are applicable to the area of assignment.
• Competent keyboard skills to produce accurate and well-presented reports
• Ability to work with a team and members of other departments.
• Ability to deal effectively and tactfully with residents and their families.
• Ability to communicate both orally and in writing to others in order to convey information effectively.
• Strong attention to detail.
• Ability to handle sensitive documents or other confidential information.
• Ability to manage time and be efficient and effective in the completion of multiple assignments simultaneously in a constantly changing environment to meet daily, weekly, and monthly deadlines.
• Ability to be a self-starter and motivated to complete work with a sense of urgency.
• Evidence of flexibility and problem‐solving skills.
• Strong attention to detail.
• Ability to work well under pressure and meet deadlines.
• Ability to arrange things or actions in a certain order or pattern according to a specific rule or set of rules (i.e., patterns of numbers, letters, words, pictures, mathematical operations).
• Ability to follow prescribed and detailed procedures to solve moderately complex problems and collect data, establish facts and draw valid conclusions.
• Ability to give full attention to what other people are saying; taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
• Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar including the ability to comprehend written sentences and paragraphs in work related documents.
• Ability to manage time and be efficient and effective in the completion of assignments.
• Knowledge of arithmetic and their applications specific to the position.

Physical Demands and Abilities

The physical demands and work environment characteristics described herein are representative of those that must be met by an employee to successfully perform the essential duties of this job. Reasonable accommodation will be made to enable individuals with disabilities to perform the essential functions.

• Ability to look at a computer screen for long periods of time.
• Ability to communicate via telephone.
• Ability to sit for long periods of time.
• Manual dexterity that allows for the ability to type, sort documents, file.
• Ability to move boxes of files, office and facility supplies, etc. The objects to lift, carry or move could weigh up to 20 pounds.
• Ability to listen to and understand information and ideas presented through spoken words and sentences.
• Ability to communicate information and ideas in speaking and writing so others will understand.
• Ability to identify and understand the speech of another person.
• Ability to see details at close range (within a few feet of the observer).
• Ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
• Ability to operate standard business equipment such as fax, computer, printer, copier, etc.
• Is subject to exposure to infectious waste, diseases, conditions, etc.
• Must be able to assist with the evacuation of residents.
• Must be able to relate to and work with ill, disabled, elderly, emotionally upset and at times hostile people within the facility.

 Required Education and/or Experience

• High school diploma or general education diploma (GED). Additional years of education in a field related to the area of assignment are preferred.
• Experience in a long-term health care or medical setting is highly desired but not required.

 Other Requirements

• May be required to attend activities outside the facility to stay abreast of new developments, best practices, and statutory and regulatory changes.
• May be required to work evenings, weekends and holidays.
• Pursuant to the Drug Free Workplace Act of 1988, all employees must remain drug free and alcohol free when reporting to work, while at work and while engaged in any work related activities.
• Comply with all Healthcare Act rules and regulations and any related laws and regulations.

A complete job description which outlines qualifications and physical demands and abilities is on file in Human Resources and available upon request.

Note

This document and the statements contained within it are intended to describe the general nature and level of work being performed by the employee assigned to this position. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the employee.

EOE

We are committed to ensure fair and equal treatment for everyone we employ and as such, we are a proud Equal Opportunity Employer. We value diversity and believe employment, training, and promotional opportunities should be available to all persons without regard to race, color, gender (including gender nonconformity, gender identity, status as a transgender individual, and sexual orientation), sex (including pregnancy), age, religion, national origin, ethnicity, physical or mental disability, genetic information, political affiliation, protected veteran status or membership in the armed services, or any other consideration that is protected by applicable federal, state, and local law.