Licensed Practical Nurse

Medical Records Clerk

Assists the clinical department and program office with the clerical duties associated with all aspects of medical record keeping, chart audits, DME management, aide scheduling and office support.

Essential Job Functions/Responsibilities

1. Maintains and updates patient admission files in PAS.

2. Completes admission audit and communicates issues/problems to the Clinical Director.

3. Inputs updates into current software system any information or changes relating to insurance, level of care, staff assignment and/or discharge.

4. Scans and files all paper clinical data, hand signed orders and consents into patient records.

5. Ensures plan of care/comprehensive assessment update/recertification are opened in a timely manner to allow staff to document their summaries prior to team.

6. Ensures plan of care/comprehensive assessment update/recertification are resolved once approved by Clinical Director or designee.

7. Tracks and emails as appropriate certification/recertification statements/POC/CA and all orders.

8. Runs unresolved orders report weekly to track unsigned orders.

9. Maintains patient on-call book.

10. Contacts physician office, hospital or nursing facility in a timely manner in order to obtain current information, signatures or any other information pertinent to the patient's admission and their hospice chart.

11. Assists as needed with providing information necessary for annual report and other patient data which may be requested.

12. Receives visit logs from all staff.

13. Inputs all visit logs of staff not electronically documenting into current software system and compares visit logs to contact visit reports weekly.

14. Tracks and ordering durable medical equipment (DME) and medical supplies.

15. If requested, participates in team meeting and is responsible for ensuring all documentation and electronic records are present as requested at team meeting.

16. Responsible to maintain the team meeting sign-in sheet, and ensures that the team agenda is attached.

17. Responsible for closing clinical/bereavement charts, and preparing charts beyond thirteen (13) months so that they may be moved to off-site storage.

18. Communicates with the Clinical Director in order that the charts are sent to off-site storage.

19. Maintains and orders office supplies.

20. Schedules and coordinates the hospice aide daily assignments to ensure the patient receives the services the patient needs.

21. Performs intake tasks as assigned.

22. Registers staff/patients with vendors such as pharmacy/EMR/supply company as directed

23. Assist with human resource functions as directed.

24. Distribute satisfaction surveys and compile results.

25. Type letters, reports and other materials as requested.

26. Answers the telephone in professional manner and channels the call accordingly.

27. Interacts with other disciplines as needed to ensure support.

28. Participates in Quality Assessment and Performance Improvement activities.

29. Completes all other duties as assigned/requested.

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Position Qualifications

1. High school graduate or equivalent.

2. One (1) year medical records experience, preferably in home health or similar operation.

3. Electronic medical record experience preferred.

4. Positive interpersonal skills and good organizational skills.

5. Good computer skills.

6. Is flexible, cooperative and self-directed in fulfilling roles.

7. Ability to function as a member of an integrated healthcare work team.