Medical Records Clerk

Lotus Nursing and Rehabilitation Center; Orlando (FL); On-site; USD 34,000 - 44,000; Full time

Benefits offered by this job

Competitive pay

Job summary

Lotus Nursing and Rehabilitation Center in Orlando, FL is seeking a Medical Records Clerk to ensure accurate, complete, and compliant patient records from admission to discharge. You will support record management, confidentiality, and documentation across nursing units.

The role requires an associates degree in medical records or related training with 1–2 years of experience, including typing and office tasks. This is a on-site position at our facility.

Qualifications

• Associates degree in Medical Record Technology preferred.
• Completion of classes in medical terminology and HIPAA knowledge.
• One to two years of previous medical records experience; typing and office experience preferred.

Responsibilities

• Assemble, protect, and collect medical records.
• Monitor physician visits and documentation.
• Thin paper records as necessary.
• Track incomplete records and ensure their completion.
• Produce records upon request according to corporate guidelines.
• Manage medical orders and documentation.
• Perform QAPI checks for completeness and accuracy.
• Prepare and maintain charts for admissions/readmissions.
• Provide nursing stations with chart and documentation forms.
• Maintain census listings, room assignments, and admission/discharge registers.
• Prepare requests for medical information as directed by Nursing Director/Administrator.
• Manage patients' clinical records from admission to discharge.
• File and retrieve paper medical records of in-house patients.
• Process telephone orders and maintain logs.
• Maintain files in a secure area.
• Promote guidelines for documenting, storing, and retrieving information.
• Communicate updated processes and guidelines to staff.

Skills

Typing

Education

Associates degree in Medical Record Technology

Job description

Medical Records Clerk

Facility: Lotus Nursing and Rehabilitation

Competitive Pay

As a Medical Records Clerk at Lotus Nursing and Rehabilitation, you will play a crucial role in ensuring our patients' medical records are accurate, complete, and compliant with State and Federal Regulations, as well as professional standards and facility policies. You will assist in managing all aspects of patient records from admission to discharge, contributing to the quality of care provided at our wonderful facility.

Key Responsibilities:

• Assemble, protect, and collect medical records.
• Monitor physician visits and documentation.
• Thin paper records as necessary.
• Track incomplete records and ensure their completion.
• Produce records upon request according to corporate guidelines.
• Manage medical orders and documentation.
• Perform Quality Assurance Performance Improvement (QAPI) checks for completeness and accuracy.
• Prepare and maintain a supply of charts for admissions and readmissions.
• Provide nursing stations with proper chart and documentation forms.
• Maintain daily census listings, room assignments, physician/patient lists, and admission/discharge/transfer registers.
• Prepare requests for medical information as directed by the Director of Nursing or Administrator.
• Manage patients' clinical records from admission to discharge.
• File and retrieve paper medical records of in-house patients.
• Process telephone orders, including mailing, maintaining telephone order log books, and filing upon return.
• Maintain files in a secure area.
• Promote guidelines for documenting, storing, and retrieving information.
• Communicate new and revised processes and guidelines to medical records staff and others as applicable.
• Maintain the confidentiality of medical records.

Requirements:

• Associates degree in Medical Record Technology preferred.
• Completion of classes in medical terminology and knowledge of HIPAA.
• One to two years of previous experience in medical records; previous typing and office experience preferred.