Medical Records Clerk organizes, files, and retrieves patient medical records. Performs data entry, file maintenance, and other clerical processes. Being a Medical Records Clerk follows established policies and procedures to ensure effective and compliant record management. Fulfills information requests for retrieval and printing of medical records from storage or archives. Additionally, Medical Records Clerk ensures the privacy and security of all patient records. Requires a high school diploma. Typically reports to a supervisor. The Medical Records Clerk works under moderate supervision. Gaining or has attained full proficiency in a specific area of discipline. To be a Medical Records Clerk typically requires 1-3 years of related experience. (Copyright 2024 Salary.com)
Small privately owned Skilled nursing/Rehab facility is looking for an experienced Health Information Specialist/Medical Records to maintain the electronic health records and comply with state and federal regulations.
Responsibilities:
Prepares clinical record for admission and updates electronic health records.
Scans all records into the appropriate resident medical record.
Responsible for updating physician orders on a monthly basis and submits to nursing for review.
Responsible for identifying, recording, and maintaining an index of resident ICD 10 diagnostic codes.
Responsible for updating the MDS and care plan at least quarterly, preparing monthly flow sheets and submit to nursing for review.
Monitors and audits records for completeness and accuracy in accordance with facility policy and regulation and prepares and submits audit reports to administrator and director of nursing services.
Processes and maintains discharge and transfer records according to policy and regulation. Responsible for ordering all supplies and maintaining an adequate inventory of forms for nursing department. Performs other related duties as assigned.
Qualifications:
Minimum of 1 year working in medical records in a skilled nursing facility.
Excellent written and oral communication skills are essential to success.
Ability to creatively problem solve and be a team player.
Job Type: Full-time
Pay: $25.00 - $30.00 per hour
Expected hours: 40 per week
Benefits:
Schedule:
Work Location: In person
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