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Medical Records Clerk - Full-Time -

Holiday Resort Health & Rehab

Salina, KS

Job Summary

The Medical Records Clerk maintains medical records in accordance with federal and state guidelines, as well as in accordance with established policies and procedures, to assure that a complete medical records program is maintained.

Duties and Responsibilities :

• Comply with the Facility’s personnel, safety, and corporate policies and procedures.
• Comply with the nursing department’s policies and procedures.
• Report witnessed or reported allegations of resident abuse / neglect immediately to the Administrator, Director of Nursing or Unit Manager.
• Treat residents, family members, visitors, and team members with respect and dignity.
• Maintain the confidentiality of all resident and family information.
• Report to work on time and as scheduled.
• Maintain minutes of meetings / files as necessary.
• Develop and maintain a good working rapport with all departments as well as residents and families.
• Ensure notices of incomplete records / charts are given to department heads for correction.
• Follow established policies and procedures for the medical records section.
• Establish a procedure to ensure paper charts / records do not leave the section except as authorized in our policies and procedures.
• Maintain a record of authorized information requested from charts / records, i.e., type information, name of recipient, date, department, etc.
• Abstract information from records as authorized / required for insurance companies, Medicare, Medicaid, VA, etc.
• Collect paper records, assemble them in proper order, and inspect them for completion.
• Perform miscellaneous duties pertaining to medical records and assist business office personnel as required / directed.

Assist with obtaining Medicare Certifications and Recertification’s timely.

• Assist in admission, transfer and discharge procedures as necessary.
• Answer telephone inquiries concerning medical records functions.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.)
• Assure that medical records taken from the department are signed out and signed in upon return.
• Ensure Physicians’ orders, telephone orders and other records requiring signatures are received and filed.
• File active and inactive records in accordance with established policies.
• Closes and files discharged resident medical charts. Review charts for deficient information and ensure compliance for correction of documentation.

Job Requirements :

• High school graduate or equivalent. Knowledge of medical terminology
• Good customer service skills
• Ability to work within a team
• Must have basic computer skills including knowledge of electronic file creation and electronic file management
• Empathy for the elderly with the ability to be sensitive to resident and family needs / concerns
• Knowledge of documentation and legal issues preferred
• Interest in maintaining professional development and continuing education on health information issues
• If required to operate a motor vehicle for business purposes, must successfully complete the requirements contained in Facility’s Motor Vehicles policy.
• Must be able to read, write, speak, and understand the English language.
• Must be able to work beyond normal working hours and on weekends and holidays when necessary.
• Must be able to perform the essential position functions of the job with, or without reasonable accommodation.
• Employee is required to use a transfer / gait belt or to obtain the assistance of another employee when attempting to assist residents when lifting or carrying objects in excess of 25 pounds.

The employee must be aware that during the normal, routine performance of the essential functions, some of the following body movements may occur naturally, although hey may not be a requirement of the job.

Last updated : 2024-06-03