Medical Records Clerk

Medical Records Clerk

OVERVIEW :

The Medical Records Clerk is responsible for directing, planning, coordinating, and administering the

facility’s medical records program.

RESPONSIBILITIES :

Ensures that medical records are complete, accurate, and conform and state boards of health

standards

Reports any variations noted and new regulations or requirements, in accordance with standard

medical records practices

Trains staff in coding, indexing, filing, preparing and displaying of information, transcription,

medical terminology nomenclature and classification of diseases, and computer services

including such related matters as hospital organization, goals, policies and practices, and

medical records ethics, laws and regulations

Supervises and monitors the release of confidential information in accordance with rules and

regulations

Compiles statistical information and registers pertaining to the medical records department,

ancillary services, and other statistical information as assigned or requested

Supervises and coordinates the preparation of statistical information for medical staff, medical

staff committees, accreditation agencies, state agencies, and the administration

Participates and represents the medical records department in various facility committees and

medical staff committees as assigned

Appears in court when subpoenaed to testify about the authentication of medical records

Abides by the state peer review statute

Monitors communicable diseases and reports to the state BOH through the infection control

officer

Provides diagnosis codes to the fiscal services department on a timely basis to expedite filing of

insurance claims for patient services rendered as required by hospital and external agencies

Assist in the Quality Assurance and Performance Improvement (QAPI) process

QUALIFICATIONS :

EDUCATION / EXPERIENCE :

Two years medical records experience in a physician's office or other health care facility

Thorough knowledge of accepted medical-records practices including medical records ethics,

classification, and nomenclature

Knowledge of accreditation standards and state health regulations

Ability to interpret medical records department policies and procedures and to apply them in

specific situations

Thorough knowledge of federal and state regulations, laws, and utilization review committee

planning, organization, and management

Knowledge of medical staff bylaws, rules, and regulations, and the state peer review statute

High school graduate or equivalent

ART (accredited records technician) or RRA (registered records administrator) designation

preferred

SUPERVISORY RESPONSIBILITIES :

This position has no supervisory responsibilities

WORK ENVIRONMENT :

This job operates in a professional office environment

This role routinely uses standard office equipment

PHYSICAL REQUIREMENTS :

The physical demands described here are representative of those that must be met by an

employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is required to stand; walk; sit; use hands

to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; talk

or hear.

The employee must occasionally lift or move office products and supplies, up to 20 pounds.

TRAVEL :

There is no travel expected for this position