Medical Records

EngageMED • North Little Rock, AR

4d

About The Position

A nonexempt position responsible for assembling patient information into patients’ medical charts/records in accurate and complete manner. Position responsibilities vary by size of medical practice and type of technology used such as electronic medical records versus manual files.

Requirements

• High school diploma.
• Knowledge of medical office procedures and HIPAA regulations.
• Minimum two years of medical records clerk/health information technician experience, preferably in medical practice setting.
• Good reading skills and ability to follow alphabetic or numeric filing systems.
• Knowledge of biology, chemistry, health, and computer science.
• Knowledge of medical terminology.
• Knowledge of legal and ethical considerations related to patient information.
• Skill in putting information in preferred medical record system, meeting clinic standards.
• Skill in dealing with masses of information in organized manner.
• Skill in using computer and medical records software.
• Ability to alphabetize and put information (materials, forms, etc.) into chronological order.
• Ability to analyze medical records for completeness and accuracy, paying attention to detail.
• Ability to schedule time and assignments effectively.

Responsibilities

• Assembles patients’ health information including patient symptoms and medical history, exam results, X-ray reports, lab tests, diagnoses, and treatment plans.
• Checks to ensure all forms are completed, properly identified, and signed and that all necessary information is in the manual and/or computer file in preferred manner such as chronological.
• Communicates as needed with physicians and other health care professionals to clarify diagnoses or to obtain additional information.
• Submits files/documentation to physicians and other clinicians as requested for review, quality assurance checks, and other purposes.
• Indexes patients’ information/correspondence in the appropriate section of electronic records.
• Other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 11-50 employees