Medical Records Clerk

Keystone Treatment Center - Canton•Canton, SD

2d•Onsite

About The Position

We are looking to add a compassionate Medical Records Clerk to our amazing records department team! Keystone Treatment Center is a 126 Bed Treatment Center providing services to adults on an inpatient basis. Keystone is located in Canton SD, just a short drive from Sioux Falls, SD. PURPOSE STATEMENT: Perform clerical duties associated with obtaining, completing and maintaining a patient medical records. MEDICAL RECORDS SECRETARY Distinguishing Characteristics: This individual assists with maintaining medical record integrity throughout the patient’s treatment stay and beyond, in accordance with Federal, State, and CARF guidelines. This position requires an understanding of the facility’s treatment program and philosophy. This individual must work flexible hours, interact with patients and family members, provide support to medical and clinical staff, and communicate verbally and electronically with various outside entities to include, but not limited to, referral sources, medical facilities, attorneys, parole officers, law enforcement, insurance companies, AND employers. Responsible To: Medical Records Supervisor Supervision Is Approved Through: Facility monitoring activities. Direct observation. Staff meetings/in-service’s. Management meetings. Individual meetings as needed. Disciplinary and grievance procedures. Annual performance appraisal. Working Environment: Office space is provided by the facility with materials, equipment, and supplies necessary to perform assigned tasks. Physical/Emotional Demands and Working Conditions: Must display coping skills to perform a variety of job duties with an ability to prioritize requests from staff and outside entities. Critical thinking and problem-solving skills are a necessary skill to perform in this position. Work is mostly sedentary with minimal walking, standing, lifting, stooping, reaching, and bending. Occasional physical exertion (lifting 30-50 pounds) is required. Must read, write, speak, and understand English. Risk of exposure to infectious and contagious/blood borne disease. Exposure to varying and unpredictable situations (i.e. patient behavior). Subject to work schedule and shift changes.

Requirements

High school diploma or equivalent required with college or technical school preferred.
Three or more years’ experience in a secretarial role and management of medical records.
Ability to perform job duties independently, communicating both verbally and electronically with male and female patients, medical and clinical staff, and various outside entities as described above.
Working knowledge of medical and pharmaceutical terminology with an ability to transcribe dictation.
Proficient in Microsoft Office (specifically Word, Excel, and Outlook).
Must read, write, speak, and understand English.
Must display coping skills to perform a variety of job duties with an ability to prioritize requests from staff and outside entities.
Critical thinking and problem-solving skills are a necessary skill to perform in this position.

Nice To Haves

Experience in quantitative medical record reviews preferred.

Responsibilities

Process requests for medical records according to policy and procedure.
Create appropriate releases of information/consent forms and obtain patient signature.
Process newly admitted patients, working in MedHost and Best Notes.
Identify inconsistencies, errors, and missing information within Best Notes that could compromise patient care.
Process requests from staff for correspondence with outside entities
Release Weekly Summaries for each patient to outside entities.
Transcribe dictation and upload to Best Notes.
Assist patients and Medical Director with completion of patient FMLA and ST Disability forms and submit to insurance companies and/or employers.
Process Millon Tests
Exhibit clear, concise verbal and written communication as observed by direct observation.
Demonstrate telephone skills (answering, taking messages, placing on hold, and transferring calls)
Correspond verbally and electronically with staff, referral sources, attorneys, parole officers, medical facilities, insurance companies, employers, and law enforcement.
Check email and Teams multiple times throughout the day, responding as necessary to requests.
Input data into Best Notes, MedHost, and Medical Records Log.
Scan paper medical records into Best Notes.
Deliver patient records to patient units and medical or clinical staff.
Assist Clinical and Management staff with medical record audits and peer review.
Adhere to facility confidentiality policies and procedures.
Displays cooperative and positive attitude towards callers, patients, staff, and visitors.
Search and print dictated reports from transcription system and/or Best Notes
Assist with purging and inventory of paper medical records for offsite storage.
Ensure paper charts are stored in designated areas according to storage procedures.
Coordinate with other departments and staff to maintain patient confidentiality.
Attend Risk Management meetings.
Perform other duties as assigned by department supervisor.
Promotes quality improvement, staff and patient safety, and cultural diversity through department operations and by personal performance.