Medical Records Clerk

About the position

The Medical Records Clerk is responsible for maintaining all documentation of patient records, including admissions, services provided, and discharges. This role involves managing processes for monitoring the accuracy and completeness of the Electronic Medical Record (EMR) and ensuring the security and confidentiality of the records through the use of required safeguards. The clerk must be knowledgeable in all aspects of Agency policy and services.

Responsibilities

• Prints 485's, physician orders, and other clinical documentation for both Medical Surgical and Hospice.
• Sends documentation/orders to physicians via fax, mailings, and/or uploads into Doc Center.
• Checks in received signed orders in Document Manager.
• Tracks to ensure signed physician orders are received by the agency according to standard (14-30 days).
• Runs Outstanding report tracking and Incomplete report for certification/recertification.
• Follows up with the physician office for orders not received within agency guidelines and documents calls in episode notes.
• Notifies coordinator after two attempts to obtain orders if unsuccessful.
• Runs Outstanding Report for both Med Surgical and Hospice documents.
• Identifies any changes/discrepancies in physician demographics and notifies manager of finance to update.
• Identifies discrepancies on all orders of start of care date, diagnosis codes, and verification of data corruption.
• Makes corrections to the system and documents changes in episode notes.
• Obtains documentation from medical records as needed.
• Problem solves incorrect or incomplete information to ensure receipt of signed orders.
• Runs and reviews system reports to manage document tracking.
• Documents any privacy issues according to agency guidelines.
• Identifies trends related to incomplete/inaccurate documents and reports to coordinator.
• Reviews designated vendor reports to process certifications and recertifications.
• Notifies clinician to lock documents.
• Receives faxes and mail from physicians' offices and any clinical paperwork that pertains to medical records.
• Sorts received information and obtains correct medical record.
• Scans documentation into correct medical record episode.
• Reviews MOLST forms for completeness and sends to provider for signature.
• Sends IDG Notes to designated provider by fax, mail, or portal.
• Submits designated record requests to vendor for processing and documents required elements in the EMR.
• Retrieves required documents for regulatory and other agencies as needed.
• Checks that consents are on file for all patients and notifies admit clinician and manager if consent is missing.
• Cross trains to answer reception calls from front desk and overhead telephone bell assistance.
• Assists in the development of agency medical records education.
• Assists in the development of agency processes and procedures.

Requirements

• High school diploma or equivalent.
• One year of related experience preferred.
• Knowledge of medical terminology.
• Basic/intermediate skills using Microsoft Office applications, specifically Excel, Word, Access, and Outlook.