Position: Part-Time Medical Records Clerk

JOB SUMMARY:

The primary purpose of your job position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines as well as in accordance with our facility’s established privacy policies and procedures.

MAJOR DUTIES AND RESPONSIBILITIES: include, but are not limited to

• Assist in organizing, planning and directing the medical records department in accordance with established policies and procedures.
• Assist the Medical Records/Health Information Consultant as required.
• Maintain minutes of meetings. File as necessary.
• Retrieve resident records (manually/electronically). Deliver as necessary.
• Files information such as nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.
• Collect charts, assemble them in proper order, and inspect them for completion.
• Pick up and deliver resident medical records from nurses’ stations, and other designated areas as necessary.
• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.
• Maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information.
• Is subject to frequent interruptions.
• Works beyond normal working hours, weekends and holidays and on other shifts/positions as necessary.
• Maintain various registries as directed including register for admission and discharge of residents.

QUALIFICATIONS:

Must possess, as a minimum, a High School Diploma/GED. One (1) year Medical Record experience in a nursing care facility, doctor’s office, hospital, or other related medical facility preferred but not required.

KNOWLEDGE, SKILLS AND ABILITIES:

• Must be able to read, write, speak, and understand the English language.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.
• Must be knowledgeable of HIPPA and Residents Rights