Medical Records Clerk

About the role

Under the direction of the Director of Nursing or Medical Records Director (if applicable) and with consultation from the Medical Records Consultant, the Medical Records Clerk maintains the medical records in accordance with State and Federal Regulations as well as professional standards of practice and facility policies and procedures to ensure complete, timely, and accurate medical records. The Medical Records Clerk is responsible for managing all aspects of the medical patient record from admission to discharge.

Responsibilities

• Assembles, protects and collects records
• Monitors physician visits and documentation
• Thins paper record
• Tracks incomplete records
• Produces record on request according to corporate guidelines
• Manages orders
• Performs Quality Assurance Performance Improvement (QAPI) checks for completeness and accuracy
• Performs any miscellaneous work assignments as may be required

Qualifications

• High school diploma required
• Associates degree in Medical Record Technology preferred
• Completion of classes in medical terminology and knowledge of HIPAA
• One to two years previous experience in medical records
• Previous typing and office experience preferred