Medical Records Clerk

General Summary:


Responsible for maintaining GMG Electronic Medical Records (EMR) by importing and organizing documents correctly/timely manner. Receives documents from internal sources, external medical offices/facilities in paper and electronic formats. Reviews medical records for accuracy and completeness. Fulfills properly executed record requests. Maintains HIPAA Compliance and serves as a resource to GMG staff.

Supervisory Responsibilities:

General Requirements:

This position has no supervisory responsibilities.

All duties performed will be done accurately and in a timely manner.

1. Exercises tact and courtesy when dealing with patients, visitors, physicians, and coworkers.
2. Maintains strictest member and company confidentiality. Ensures member health information is secured each day.
3. Participates in educational programs as needed.
4. Assists with special projects as needed.
5. Other duties as assigned.

Essential Job Responsibilities:

1. Regularly retrieves paper documents from the Clinical Areas following defined protocols. Verifies that paper documents are properly labeled to ensure the right patient and right medical record. Documents any records submitted without valid name, DOB, or other identifying information according to established protocols.
2. Scans paper documents into a defined software system to prepare for import to EMR. Imports documents into the patient record correctly: Right Patient, Right Record, Right Document Designation, Right Date of Service, Right status (signed/unsigned).
3. Obtains electronic records from external clinics for follow-up by verifying patient authorization for proper document release.
4. Organizes and evaluates patient medical records. Reviews medical records for accuracy and completeness.
5. Releases records accurately and in a timely manner while maintaining HIPAA compliance, including release of records to patients, referral specialists, QI entities, legal requests, etc.
6. Reviews subpoenas to ensure records are accurately produced according to request and delivered to appropriate parties within defined-time periods. Documents record releases correctly in EMR.
7. Performs other special Medical Record review activities (Home Health Records, Diabetic Shoe Documentation, etc.) as defined.
8. This position will require driving a personal vehicle; therefore, employees must successfully complete a motor vehicle history check, possess and maintain a current valid Texas Driver License, and provide proof of current insurance to be subject to mileage reimbursement.

Education and Training:


Minimum high school education or equivalent

Experience:

Minimum of three (3) years of experience in a clinic, doctor's office, hospital, or similar setting required.

Other Requirements:


Knowledge of medical terminology required. Computer Skills: Skilled in use of computer/EMR systems. Knowledge of Word processing software, spreadsheet software, Internet, and database software.

Work Environment:


Depending upon the area and location assigned, may be 100% clinical setting or office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a clinic environment.

Mental / Physical Requirements:


Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 15 lbs. Close vision and ability to adjust focus. Must be able to work efficiently under pressure.

Additional Information:


Gonzaba Medical Group is seeking team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and core values.


Other Duties As Assigned:


The above job description is not intended to be an all-inclusive list of duties and standards of the position. Team members will follow any other instructions and perform related duties, as assigned by their supervisor. Responsibilities, knowledge, skills, abilities, and work environments may change as needs evolve.