Medical Records Clerk

MEDICAL RECORDS CLERK

Job Description :

The Medical Records Assistant (MRA) is responsible for the orderly, concise and timely filing of the resident's medical record. The MRA audits, files and stores the resident's medical records in accordance with the facility's policies and procedures, current standards of care and practice and applicable state/federal regulations. The MRA reports directly to the Director of Nursing Services (DON).

Essential Job Duties:
• Understands and agrees with the facility's philosophy and goal to maintain, improve and/or enhance each resident's quality of care and quality of life.
• Audits resident records and files from chart copy to active holding file as required by the facility's policies and procedures, current standards of practice and applicable state/federal requirements.
• Accurately maintains schedules and records of medical records transactions.
• Receives, records and dispatches medical records to the physician or others for signatures in a timely fashion as required the facility's policies and procedures, current standards of practice and applicable state/federal requirements.
• Reviews and organizes medical records to provide an accurate, factual and systematic record of care for each resident.
• Understands and complies with state/federal laws that govern the resident's right to medical privacy unless authorization to disclose has been given by the resident or by the resident's legal responsible party.
• Maintains, protects and stores medical records for residents who no longer reside in the facility as indicated by the facility's policies and procedures, current standards of practice and applicable state/federal requirements.
• Maintains, protects and stores medical records for residents who currently reside in the facility as indicated by the facility's policies and procedures, current standards of practice and applicable state/federal requirements.
• Communicates medical records concerns or issues to the DON in a timely and factual manner. Ensures date deadlines and other requirements are consistently maintained in a timely fashion as required by state and federal regulations.
• Encodes data into the computer. Prints monthly variance reports as requested by the DON
• Prints all end-of-month/first-of-month records in a timely fashion as required by policies and procedures of the facility and in accordance with applicable state/federal regulations.
• Performs other duties and functions as assigned by the DON.

Job Knowledge & Skills:
• Must work to familiarize him/herself with the facility's policies and procedures for medical record organization and storage.
• Must possess basic understanding of medical records principals including state/federal regulations which govern medical records.
• Must have basic understanding of computers and the ability to encode data.

Qualifications & Education:
• Must demonstrate the ability to read and write and must understand medical terminology and abbreviations.
• Must possess a high school diploma or its equivalency. Some type of advanced medical training is preferred.
• Must demonstrate a moderate level of computer literacy in order to use and access our systems and tools within our facilities to complete online tasks and documentation.
• Must be able to effectively communicate and interact professionally with staff and residents.

Physical Requirements:
• Must be able to stoop, bend, move and store boxes of medical records.
• Must be able to sit, stand, bend and move intermittently during working hours.
• Must have good vision and manual dexterity for filing forms.
• Must be willing and able to work a flexible schedule.


Please note that all candidates must be able to perform the full range of job functions as outlined in this description to be considered for this position. If you require an accommodation during the application or interview process, or to perform the essential functions of the position, please contact Human Resources.