Medical Records Clerk

Job Description

Job Description

Key Job Duties and Responsibilities 

The Medical Records Clerk maintains medical records in accordance with federal and state guidelines, as well as in accordance with established policies and procedures, to assure that a complete medical records program is maintained.

The following is a general list of key job duties and responsibilities in your position. The list is not to be considered inclusive and you will be required to perform other duties/responsibilities as assigned by an authorized supervisor. 

Duties and Responsibilities 

Comply with the Facility’s personnel, safety, and corporate policies and procedures. 

Comply with the nursing department’s policies and procedures. 

Report witnessed or reported allegations of resident abuse/neglect immediately to the Administrator, Director of Nursing or Unit Manager. 

Treat residents, family members, visitors, and team members with respect and dignity. 

Maintain the confidentiality of all resident and family information. 

Report to work on time and as scheduled. 

Maintain minutes of meetings/files as necessary. 

Develop and maintain a good working rapport with all departments as well as residents and families.

Ensure notices of incomplete records/charts are given to department heads for correction. 

Follow established policies and procedures for the medical records section. 

Establish a procedure to ensure paper charts/records do not leave the section except as authorized in our policies and procedures. Maintain a record of authorized information requested from charts/records, i.e., type information, name of recipient, date, department, etc. 

Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc. Collect paper records, assemble them in proper order, and inspect them for completion. 

Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed. Assist with obtaining Medicare Certifications and Recertification’s timely. 

Assist in admission, transfer and discharge procedures as necessary. 

Answer telephone inquiries concerning medical records functions.

Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.) Assure that medical records taken from the department are signed out and signed in upon return. 

Ensure Physicians’ orders, telephone orders and other records requiring signatures are received and filed. File active and inactive records in accordance with established policies. 

Closes and files discharged resident medical charts. Review charts for deficient information and ensure compliance for correction of documentation.

Other related duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility. Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed. 

Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately. 

Report equipment malfunctions or breakdowns to your supervisor as soon as possible. 

Ensure supplies have been replenished in work areas as necessary. 

Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of work day, etc. 

Maintain confidentiality and security of all pertinent resident care information to assure resident rights are protected. Knock before entering a resident’s room.  

Assure that resident rights are fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints, are followed. 

Responsible for knowing relevant State and Federal laws and regulations; especially related to the provision of resident care and documentation.

Essential Job Duties/Physical Requirements 

The following is a general list of key job/physical requirements for your position. The list is not to be considered inclusive and other job/physical requirements may be necessary as deemed by the Facility. 

• Regular worksite attendance. 

• High school graduate or equivalent. Knowledge of medical terminology 

• Good customer service skills 

• Ability to work within a team 

• Must have basic computer skills including knowledge of electronic file creation and electronic file management

• Empathy for the elderly with the ability to be sensitive to resident and family needs/concerns 

• Knowledge of documentation and legal issues preferred 

• Interest in maintaining professional development and continuing education on health information issues

• If required to operate a motor vehicle for business purposes, must successfully complete the requirements contained in Facility’s Motor Vehicles policy. 

• Must be able to read, write, speak, and understand the English language. 

• Must be able to work beyond normal working hours and on weekends and holidays when necessary.

• Must be able to assist in the evacuation of residents during emergency situations. 

• Must be able to perform the essential position functions of the job with, or without reasonable accommodation.

• Employee is required to use a transfer/gait belt or to obtain the assistance of another employee when attempting to assist residents when lifting or carrying objects in excess of 25 pounds. The employee must be aware that during the normal, routine performance of the essential functions, some of the following body movements may occur naturally, although hey may not be a requirement of the job.

• Primary Physical Requirements:

• Lift up to 10 lbs: Constantly 

• Lift 11 to 25 lbs: Occasionally 

• Lift 26 to 50 lbs: Rarely 

• Lift over 50 lbs: Not Required 

• Carry up to 10 lbs: Constantly 

• Carry 11 to 25 lbs: Occasionally 

• Carry 26 to 50 lbs: Not required 

• Carry over 50 lbs: Not required 

• Reach above should height: Frequently 

• Reach at shoulder height: Frequently 

• Reach below shoulder height: Constantly 

• Push/Pull: Frequently 

• Hand Manipulation:

• Grasping: Frequently 

• Handling: Constantly 

• Torquing: Not Required 

• Fingering: Constantly 

• Other Physical Considerations 

• Twisting, Bending, Crawling, Squatting, Kneeling, Crouching, Climbing and Balancing may be required. 

• Employees may be required to operate and automobile and various games. 

• Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and hostile people within the Facility.  

• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.