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Job Summary:
Works under the supervision of the Site Manager. The medical record includes information the patient provides concerning their symptoms and medical history, the results of examinations, reports of x-rays and laboratory tests, diagnosis and treatment plans. The Medical Records Clerk organizes and ensures documents have been signed by clinician and files in the proper location in the chart. The clerk will prepare charts for the following day and pull transcription from fax and attach to chart for doctor’s signature.
Supervisory Responsibilities: N/A
Essential Duties and Responsibilities:
Administrative Functions:
- Assures that all medical records are filed in accordance with filling procedures
- Maintains staff’s medical records in separate file cabinet
- Maintains staff’s medical records confidential at all times
- Maintains and up-dates medical records pull out system
- Files all in-coming reports, lab results, x-ray report, and all records pertaining to patient’s medical status. Places medical record in providers work box for him/her to review and sign all reports
- Responsible for processing all incoming medical record requests (copies record and mails it to requestor)
- Responsible for processing subpoenas and or any legal agencies medical record requests
- Keeps a record of all in-coming subpoenas
- Pulls medical records for following day
- Places all necessary forms needed by the provider in medical record
- Reviews medical records after services have been rendered to assure all documents are complete, signed, dated, and file under the correct section of the medical record
- Provides back-up for frontline staff when appropriate
- Pulls medical records for Peer Review and Chart Audits
- Maintains and up-dates medical records requests
- Restricts access to medical records department to unauthorized personnel
- Answers/returns phone calls related to medical records
- At the end of each work day makes sure that all medical records are in the medical records room and locked
Qualifications:
Minimum Qualifications (Education and Experience):
- Graduate of approved high school or GED equivalent
- One year work experience.
Knowledge, Skills and Abilities:
- Excellent oral and written communication skills
- Effective interpersonal skills
- Ability to use office equipment i.e. copier, fax machine, POS machine
- Bilingual in Spanish/English
Additional Requirements: (Licenses/Certifications)
- All staff that is presently working within a clinic is required to have a Current and Valid CPR and First Aide certification on file with the Human Resources Department. This is for clinical and administrative staff. This new license requirement is mandatory for continued employment, CPR and First Aide certification must be obtained through the American Heart Association. Internet certificates do not comply and for this reason are not valid.
