Job Title/Position: Medical Records Clerk

Reports To: Executive Director

JOB DESCRIPTION SUMMARY 

Assists the clinical department in matters associated with recordkeeping, chart audits, statistical reports and typing. Responsible for entering new admits, changes in level of care, discharges and contact visits as well as physician orders, resolving orders, entering physician signature dates, face to face completion dates into electronic medical record. Ordering of supplies and other support tasks required.

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES 

1.      Maintains and updates patient files in EMR.

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

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

4.      Scans and files all 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 IDG team meeting. 

6.      Tracks certification statements/POC/CS recertification’s and physician orders after RN emails to med records. Run unresolved order reports from admin console weekly to track unsigned orders.

7.      Maintains patient on-call book.

8.      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.

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

10.   Receives visit logs from all staff. 

11.   Compares visit log to contact visit report weekly.

12.   May assist with tracking and ordering durable medical equipment (DME) and medical supplies.

13.   Participates in Quality Assessment and Performance Improvement activities.

14.   If requested, participates in team meeting and is responsible for ensuring all documentation and charts are present as requested at team meeting. 

15.   Responsible to maintain the team meeting sign-in sheet, and ensures that the team problem list is attached.

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

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

18.   Type’s letters, reports and other materials as requested.

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

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

21.   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.      Positive interpersonal skills and good organizational skills.

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

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