Medical Records Clerk

Responsibilities

• Retrieves paper documents from the Clinical Areas following defined protocols.
• Verifies that paper documents are properly labeled to ensure the right patient and right medical record.
• Documents any records submitted without valid name, DOB, or other identifying information according to established protocols.
• Scans paper documents into a defined software system to prepare for import to EMR.
• Imports documents into the patient record correctly: Right Patient, Right Record, Right Document Designation, Right Date of Service, Right status (signed/unsigned).
• Obtains electronic records from external clinics for follow-up by verifying patient authorization for proper document release.
• Organizes and evaluates patient medical records.
• Reviews medical records for accuracy and completeness.
• Releases records accurately and in a timely manner while maintaining HIPAA compliance, including release of records to patients, referral specialists, QI entities, legal requests, etc.
• Reviews subpoenas to ensure records are accurately produced according to request and delivered to appropriate parties within defined-time periods.
• Documents record releases correctly in EMR.
• Performs other special Medical Record review activities (Home Health Records, Diabetic Shoe Documentation, etc.) as defined.

Requirements

• Exercises tact and courtesy when dealing with patients, visitors, physicians, and coworkers.
• Maintains strictest member and company confidentiality.
• Ensures member health information is secured each day.
• Participates in educational programs as needed.
• Assists with special projects as needed.