MEDICAL RECORDS CLERK

Job Description

Culture Statement: At Blue Mountain Hospital, we are committed to a culture of excellence, empowerment, accountability, and affirmative communication.


Value Statement: Blue Mountain Hospital strives to exemplify values of Excellence, Integrity, Respect, Cultural Sensitivity, Compassion, Accountability, Stewardship and Collaboration.


Vision Statement: Blue Mountain Hospital vision is to be the standard for rural hospitals.

Mission Statement: Blue Mountain Hospital is committed to providing an atmosphere of excellence in healing, quality physician care and inspired employees.

Occupational Title: Medical Records Clerk


Department: Business Office

Reports To: Assistant Billing Manager

Facility Location: Blue Mountain Hospital Remote-Onsite-Cedar Mesa - Warehouse

Position: Part -time


Description:

The Medical Records Clerk plays a vital role in maintaining the accuracy, completeness, security, and timely flow of patient health information throughout the organization. This position supports daily chart management, record requests, physician documentation follow-up, regulatory reporting, audits, and coordination between departments including Billing, Coding, Procurement, Clinical Services, and Administration. The ideal candidate is highly organized, detail-oriented, able to manage multiple priorities, and committed to patient confidentiality and regulatory compliance.

Key Responsibilities

Daily Chart & Documentation Management

• Collect paperwork daily from Med/Surg, Surgery, ER, Clinic, and other departments.
• Separate charge sheets, DJOs, and supporting documentation; route items to Billing or Procurement as needed.
• Review records for signatures, dates, labels, and completeness.
• Scan documents into the EMR and organize paper records for retention or shredding.
• Follow up on incomplete or unsigned documentation and update daily tracking reports.

Visit Completion & Coding Readiness

• Review new and outstanding visits to confirm required documentation is complete.
• Forward completed visits to Coding for claim processing.
• Document deficiencies in tracking logs and patient accounts.
• Send reminder emails or follow-up notices for missing items.
• Monitor unresolved visits until completion.

Medical Record Requests

• Monitor fax, email, voicemail, and request folders for incoming record requests.
• Process and fulfill authorized requests in a timely manner.
• Maintain accurate logs of disclosures and completed requests.
• Ensure all releases comply with HIPAA and privacy regulations.
• Communicate with requestors regarding status or needed information.

Durable Joint Orders (DJOs)

• Review DJOs for signatures, labels, provider information, and required details.
• Add diagnosis codes and verify insurance coverage when needed.
• Scan completed forms into the patient chart.
• Prepare supporting records, face sheets, and insurance information for vendors.
• Transmit, track, and file completed orders.

Birth Certificates & Vital Records

• Enter and prepare birth certificate information for parent signatures.
• Verify medical details after discharge for accuracy.
• Finalize records in the applicable system and submit required forms.
• Process paternity documentation as needed.
• File completed birth records securely.

Claims Worklist Support

• Review accounts in the claims worklist for documentation issues.
• Resolve chart deficiencies that delay billing or claim submission.
• Coordinate with Billing and Coding to clear holds.
• Update account notes and tracking tools.
• Assist with timely claim readiness.

Peer Review & Reporting

• Gather data and complete monthly Medical Staff reports.
• Enter statistics into reports, spreadsheets, or presentation slides.
• Prepare and distribute peer review results to providers
• Track completion and maintain reporting records.
• Select and submit charts for quarterly provider peer review

Audits & Regulatory Reporting

• Prepare quarterly chart audits and submit records to auditors.
• Complete quarterly death reporting and required mortality forms.
• Support annual Birth Certificate audits.
• Run annual Cancer Registry reports and complete submissions.
• Maintain readiness for regulatory reviews and compliance requests.

Requirements

Experience, Training, and Qualifications needed to perform the job:

• Athena (EMR) knowledge and 6 months experience
• Knowledge of HIPAA, confidentiality, and release of information processes.
• Familiarity with EMR systems, spreadsheets, and Microsoft Office programs.
• Strong attention to detail, organization, and time management.
• Understanding medical terminology, insurance, or coding is preferred.
• High school diploma or equivalent required; healthcare office experience preferred.
• Type a minimum of 30 WPM

General Requirements:

In addition to the specific duties listed above, the Employee is required to do the following:

• Any tasks, projects, or actions that are reasonably within the scope of the Employee's position or employment, which the Employee's supervisor, any member of BMH's management, or BMH's administration team-asks of the Employee. Tasks, projects, or actions are "reasonably within the scope" of the Employee's employment or position unless the same are so far removed therefrom that no legitimate argument can be made that such tasks, projects, or actions are in any way related to BMH or the Employee's employment or position within BMH.
• Act as professionally as should normally be required in a medical organization. This shall include giving all appropriate respect and deference to licensed medical providers and behavioral health providers (hereafter jointly referred to as "Providers"). Providers include, but may not be limited to physician assistants, nurse practitioners (or similar), and Physician Assistants.
• Keep all BMH business and patient information strictly confidential and adhere to all other BMH confidentiality policies and procedures, as well as all laws affecting confidentiality.
• Refrain-whatsoever-from intentionally, purposely, knowingly, or negligently engaging in any conduct, actions, or speech that may cause concern, apprehension, confusion, or annoyance on the part of any BMH patient toward BMH as an organization or any BMH employee.
• Work congenially and cooperatively at all times with all other BMH employees. This includes maintaining a pleasant demeanor and attitude and executing position duties and administration's/management's other requests in a timely manner, diligently, and with a positive attitude. This requirement further includes refraining from personally degrading any other person or BMH employee. As part of this requirement, the Employee must refrain from engaging in gossip about any BMH employees and/or patients.
• Communicate complaints about BMH, its policies, procedures, managers, administrators, and/or other employees-only to and through the appropriate BMH channels, which are limited to BMH's management chain of command. No complaints, judgments, or degrading comments about BMH, its policies, procedures, managers, administrators, and/or other employees-should be shared with anyone other than the appropriate persons within BMH's management chain of command who have the ability to work to remedy any related problems. Unless the Employee's direct supervisor is part of the problem or complaint-problems and complaints should first be voiced to the Employee's direct supervisor and upward therefrom through BMH's internal management chain of command as appropriate and necessary. It is an absolute dereliction of this duty by the Employee if the Employee ever-directly or indirectly (in conjunction or planning with others)-makes complaints or problems publicly known to anyone other than BMH's management team or administrative team (neither include BMH Board Members).
• If applicable (having access to), check the Employee's BMH email no less frequently than once daily.
• Absolutely refrain from communicating or releasing any "Private BMH Information" to the media and/or non-BMH persons or entities-without formal approval to do the same by BMH's CEO. "Private BMH Information", for purposes of this requirement, includes: (1) all information that requires confidentiality pursuant to any BMH policies or procedures; (2) all information that is protected by HIPAA or other applicable laws; (3) all information relating to BMH's internal business workings, strategies, or plans; and (4) all information relating to any BMH employee or contractor. This requirement remains applicable and shall stand regardless of whether the information being requested is of a private or public nature-if the information sought fits any of the above listed types. Finally, this requirement remains applicable at all times, including when the Employee is off duty or away from BMH's premises.

We offer the opportunity to work with a dynamic team providing care to medically underserved communities. BMH hires in accordance with NPEA standards.