Job Title: Medical Records Clerk / Health Information Technician

Job Summary: Responsible for assembling patient information into designated medical charts/records in an accurate and complete manner.

Job Responsibilities/Tasks:

• Communicates, when needed, with physicians and other health care professionals to clarify medical record information (diagnoses, treatments, etc.) and to obtain any additional information required.
• Ensures that all necessary information is housed in patients’ medical records (manual or computer file) and done so in the practice preferred style (chronological).
• Organizes patients’ health information including symptoms, medical history, examination results, lab tests, ancillary reports (x-ray, ultrasound, etc.), diagnoses, and treatment plans.
• Provides patient charts/documentation requested for legal use while adhering to patient consent/confidentiality protocols.
• Reviews medical records to ensure all relevant forms are completed, properly identified, and signed by necessary parties.

Education:

• High School Diploma or Equivalent
  • Required
• Associate’s Degree from community/junior college
  • Preferred

Experience:

• Preferred 2 years of medical records clerk/health information technician experience in a healthcare environment

Disclaimer: This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.