Medical Records Clerk - Home Care organizes, files, and retrieves patient medical records for a home care office. Files various medical documentation, including patient notes, radiology reports, and lab results. Being a Medical Records Clerk - Home Care performs related clerical duties. May be responsible for clerical duties related to patient admission/discharge. Additionally, Medical Records Clerk - Home Care works with both paper-based systems and electronic medical records (EMR). Typically requires a high school diploma or its equivalent. Typically reports to a supervisor or manager. The Medical Records Clerk - Home Care possesses a moderate understanding of general aspects of the job. Works under the close direction of senior personnel in the functional area. May require 0-1 year of general work experience. (Copyright 2024 Salary.com)
Job Summary: Medical Records Clerk is responsible for maintaining, incorporating, and accurately accounting for all medical records information of the patient. Medical Records Clerk maintains patient records which include information that the patient was provided concerning his or her symptoms and medical history, the results of examinations, reports of x-rays and laboratory tests, diagnoses, and treatment plans for home health care. Medical Records Clerk ensures that patients’ medical chart are complete, that all forms are completed and signed by the visiting clinician and are uploaded in the electronic filing system. Reports to: Director of Patient Care Services
Essential Functions: 1. Responsible for accessing, maintaining and auditing all patient medical records for completeness including consents, MD orders, all completed/uploaded notes, 485, face to face and OASIS.
2. Ensures medical record systems are maintained in compliance with the State and Federal regulations.
3. Executes all daily medical records functions including implementation of medical records policies and procedures.
4. Provides copies of medical records to authorized users in accordance to the medical records policies and procedures.
5. Maintains effective communication with others, both inside and outside the department, to give or obtain needed information.
6. Ensures that Physician’s orders, telephone orders and other records requiring signatures of the Physicians are received and filed within the required time frame no later than twenty five (25) days. Sends and follows up unsigned orders, 485s and face-to-face forms from Physicians for signature within twenty five days (25) days from the date forms were created.
7. Monitors aged unsigned physician orders and submits second and third requests for signed orders to overdue physicians, calls or visits the offices of seriously overdue physicians.
8. Ensures that Clinical visit notes, lab work and other records requiring signatures of the Clinicians are completed and electronically filed within the required time frame no later than seventy two (72) hours from the date of visit.
9. Receives, scans and uploads signed patient consents, authorizations, signed MD orders, signed 485s and signed Face-to-Face Encounter with a Physician form within twenty five (25) days from the date these forms were created.
10. Closes and files discharged patients’ medical charts. Reviews charts of discharged patients and ensures compliance of documentation.
11. Assists in recommending procedures to ensure patient records are properly completed, signed, indexed before filing.
12. Ensures implementation of functions or activities involving the use or disclosure of individuality identifiable health information as defined by the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act (“HIPAA Rule”).
13. Maintains the use of the clinical records information system and maintains a comprehensive working knowledge of the system including upgrades and enhancements.
14. Receives and follows work schedule/instructions from Director of Patient Care Services.
15. Executes posting of daily visit route sheets and checking of corresponding visit notes with route sheets for completeness in a timely manner in accordance with the Payroll policies.
16. Other related duties and responsibilities that may become necessary or appropriate to meet the administrative needs of the agency.
Knowledge, Skill and Experience:
1. Minimum Education (or substitute experience) required: Must possess, as a minimum, a high school diploma or equivalent (GED).
2. Minimum Experience required: 6 months to 1 year of relevant experience and/or training, or equivalent combination of education and experience.
3. Skills Required: Computer skills required. Must be able to type a minimum of 45 words per minute. Possession of strong organizational skills. Excellent verbal and written communications skills. Possess exceptional interpersonal communication skills. Ability to work independently on assigned tasks as well as accept direction on given assignments. Able to work collectively with the administrative team associates. Demonstrates organization, assertiveness, flexibility and cooperation in performing job responsibilities.
Physical Job Description
Typical Working Conditions: Typical office environment – no unusual exposures. Equipment Used: Computer keyboard, telephone Essential Physical Tasks: Must occasionally carry boxes of patient information documents weighing approximately 30 lbs. Work at computer monitors for prolonged periods must guard against eyestrain and muscle pain.
Job Type: Full-time
Benefits:
Schedule:
Experience:
Work Location: In person