Medical Records Clerk - Lord Chamberlain Nursing and Rehabilitation Center : Job Details

Medical Records

• Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.
• Assist in organizing, the medical records section in accordance with established policies and procedures.
• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
• Collect, assemble, check and file resident charts as required.
• Ensure incomplete records/charts are returned to nursing service for correction.
• Assist the Medical Record Technician as necessary.
• Follow established policies and procedures for the medical records section.
• Maintain a record of authorized information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
• Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
• Collect charts, assemble them in proper order, and inspect them for completion.
• Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
• Assist in admission, transfer and discharge procedures as necessary.
• Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.)
• Assure that medical records taken from the department are signed out and signed in upon return to the department.
• File active and inactive records in accordance with established policies.
• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of the Medical Records Clerk.
• Other related duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility.
• Maintain loose filing in alphabetical order and process loose filing.

Admission Functions

• Maintain a supply of pre-filled charts for weekend and off-shift admissions/readmissions.
• Attach preadmission documentation to admission papers as appropriate and prepare medical records for admisssions based on policies/procedures.
• Process Admission problems to proper authority, i.e., supervisor, social service, nursing service, etc.
• Refer admission problems to proper authority, i.e., supervisor, social service, nursing service, etc.
• Follow Admission policies and procedures for informing appropriate departments of admissions/readmissions.
• Collect or receive discharge medical records from nursing office daily.
• Dismantle and create discharge medical record.
• Place active medical record in discharge order as stated in the medical record policies and procedures.
• Analyze medical records for completion and return to nursing office for completion as needed.
• File medical record as closed upon completion.

Maintain incomplete medical record file.

Educational Requirements

• Must possess, as a minimum, a high school diploma.

Experience

• Must have working knowledge of ICD-9-CM coding

• Must have a working knowledge of medical terminology.

• On-the-job training provided in medical record procedures.
• Computer Knowledge

Full time benefits

• Competitive pay
• Shift differentials
• Medical, Dental and Vision Insurance*
• PTO*
• 401 (k) with employer match*
• Employer Paid Life Insurance
• Paid Meal Period
• 8 Paid Holidays
• Employee Assistance Program
• Longevity Credit*
• Short- & Long-Term Disability*

Medical Records Clerk- Pay Rate

• TBD