Medical Records Clerk

HumanGood • Boise, ID

8d • Onsite

About The Position

We are looking for a detail-oriented Medical Records Clerk to join our amazing team. The role assists the Director of Nursing and/or Health Services Director in maintaining the facility's clinical record system. Reviews, audits and updates charts on paper and/or on computer, including physicians order sheets, medication sheets and treatment sheets and ADL sheets; processes admissions and discharges. Responsible for following standards of practice and facility policies and procedures to ensure complete, timely, and accurate medical records. Will manage all aspects of the medical patient record from admission to discharge. Also assists in implementing record procedures for the Clinical Records Unit.

Requirements

• Detail-oriented

Responsibilities

• Initiate the medical record by creating and processing the patient care record folder
• Gather patient information by collecting information from a variety of sources; interacting with registration areas and physician’s offices
• Maintain master patient index by completing assigned portion of daily audit trail; corrects and communicates problems according to established procedures
• Maintain record availability and purge as required
• Retrieve medical records as needed by various authorized professionals, following chart-out procedures; documenting reasons
• Deliver charts to assigned areas of the health center
• Keep health care providers informed by communicating availability or unavailability of the record
• Maintain continuity of work operations by documenting and communicating actions, irregularities, and continuing needs
• Work with state officials during Survey
• Maintains the facility's clinical record system and assists in implementing record procedures
• Serves as a member of OBRA team
• Performs quantitative and qualitative audits for compliance including: patients' charts; medical records for physician telephone orders, physician monthly order, advanced directive status, lab tests and other assigned audits.
• Conduct Medication Admin Record (MAR) Audit
• Performs chart audits and updates including physician visits monthly
• Fax or mail medical records when requested
• Responsible for inputting any new or changed orders in the computer daily, including deleting any orders no longer needed
• Files medication, treatment; ADL sheets into the charts monthly following previous months processing
• Files misc. medical records daily
• Performs thinning of charts and files thinned records in overflow monthly
• Performs admission process as needed including preparing medical record and inputting and printing physician orders, medication & treatment sheets & ADL sheets.
• Prints armbands for all new admissions and when needed; prints cardex for new resident & gives to D.S.D.
• Processes discharge charts including putting charts in discharge order sending necessary forms out to physician for completion & signature, upon return of completed forms, assembles charts and files charts in main dining room file cabinet
• Audits all discharged charts for compliance & notifies responsible person for any follow-up

Benefits

• Health, Dental and Vision Plans
• 20 days of paid time off (increases with years of service)
• 7 company holidays
• 401(k) with up to 4% employer match
• HSA option with employer contribution
• Tuition Reimbursement
• Continuing education programs
• $25/line unlimited cell phone plan (plus taxes and fees)
• Cell Phone Stipend
• 5-star employer-paid employee assistance program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed