Medical Records Clerk

Position Summary

The Medical Records Clerk is responsible for managing and maintaining patient medical records for the facility. This includes preparing, storing, retrieving, and reviewing records to ensure accuracy, completeness, and compliance with organizational policies and HIPAA regulations. The role may function independently or as part of a medical records team.

Qualifications

• High School Diploma or equivalent.
• Minimum of one (1) year of experience in a medical office or healthcare setting.
• Training in an accredited medical records program or experience with an established medical records system preferred.
• Working knowledge of business English, math, grammar, and spelling; ability to develop correspondence, reports, and operational directives.
• Demonstrated ability to exercise discretion and maintain patient confidentiality.
• Strong organizational, communication, and attention-to-detail skills.

Performance Expectations / Duties

• Prepare new patient charts by gathering documents and information from paper sources and/or electronic health records (EHR).
• Ensure medical records are accurately assembled and maintained in standard order.
• Scan paper records into the appropriate sections of the EHR and create digital images for storage.
• Obtain physician signatures on diagnostic studies prior to filing.
• Maintain both active and inactive patient files.
• Provide medical records to healthcare providers and administrative staff as requested.
• Prepare monthly statistics and reports regarding medical records activities.
• File paperwork and reports in patient charts accurately and in a timely manner.
• Safeguard patient records and ensure compliance with HIPAA and other regulatory requirements.
• Process release of information requests in a timely and secure manner.
• Respond to internal and external requests for patient records, retrieving and transmitting them appropriately.
• Retrieve medical records from offsite storage facilities when necessary.
• Perform clerical tasks as needed, including answering phones, faxing, and assisting with patient check-in/check-out.
• Attend and participate in required training sessions.
• Adhere to safety and security policies and participate in disaster preparedness drills.
• Respond effectively in stressful situations.
• Perform additional duties as assigned.

Organizational Expectations

• Provides a positive and professional representation of CFG Health Systems, LLC.
• Promotes a culture of safety for patients and employees through proper identification, reporting, documentation, and prevention.
• Maintains competency and knowledge of current standards of practice, trends, and developments in related scope of job role or practice.
• Adheres to infection control policies and protocols, medication administration and storage procedures, and controlled substance regulations.
• Participate in ongoing quality improvement activities.
• Completes required orientation as directed by the facility.
• Fulfills safety and security policies and procedures while on assignment.
• Upholds HIPAA and PREA regulations.
• Punctual and dependable for assigned/confirmed shifts.
• Maintains security clearance for the assigned facility.

Physical Demands

• May regularly be required to stand, sit, walk, reach, bend, kneel, crouch, or stretch, for prolonged periods of time.
• Able to communicate and understand written and verbal communication.
• The employee must be able to lift and/or move up to 50 pounds.