Medical Records Staff

Meadowcreekpostacute; Northern (KY); Hybrid; USD 32,000 - 42,000; Full time

Job summary

Meadowcreekpostacute is seeking a Medical Records Clerk to maintain accurate patient records in accordance with federal and state regulations and facility policies. You will organize, file, index, and retrieve records, support the medical records team, and help ensure timely and compliant documentation across multiple departments.

The role emphasizes attention to detail, adherence to procedures, and effective communication with nursing staff and physicians.

Qualifications

• High school diploma required.
• Experience in medical records is preferred.
• Attention to detail and accuracy.

Responsibilities

• Receive and follow work schedule/instructions from your supervisor.
• Assist in organizing, planning and directing the medical records section in accordance with established policies and procedures.
• Assist in the orientation program for all personnel in accordance with our policies and procedures.
• Assist the Medical Records consultant as required.
• Maintain minutes of meetings/files as necessary.
• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
• Collect, assemble, check, and file residents charts and personnel records as required.
• Ensure that schedules are followed as outlined for respective shifts/areas.
• Ensure incomplete records/charts are returned to nursing service for correction.
• Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing
• Follow established policies and procedures for the medical records section.
• Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
• Maintain a record of authorized information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
• Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
• Index medical records as directed by the medical records consultant.
• Maintain various registries as directed including register for admission and discharge of residents.
• Type reports for physicians as necessary.
• Collect charts, assemble them in proper order, and inspect them for competition.
• Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
• Assist in admission, transfer and discharge procedures as necessary.
• Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.).
• Assure that medical records taken from the department are signed in upon return to the department.
• File active and inactive records in accordance with established policies.
• Index medical records as directed.
• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of the Medical Records Clerk.

Education

High School Diploma

Job description

The Medical Records Clerk is charged with maintaining medical records in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained.

Information explaining the Essential Functions, Safety Factors, and the Competency Evaluation columns, as well as the Risk Exposure Category legend is provided in the “Job Position Analysis Information” section located on the last page of this job description. (Note: The number assigned to each individual column corresponds to that same number in the “Analysis” section.)

Duties and Responsibilities

Administrative Functions:

• Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.
• Assist in organizing, planning and directing the medical records section in accordance with established policies and procedures.
• Assist in the orientation program for all personnel in accordance with our policies and procedures.
• Assist the Medical Records consultant as required.
• Maintain minutes of meetings/files as necessary.
• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
• Collect, assemble, check, and file residents charts and personnel records as required.
• Ensure that schedules are followed as outlined for respective shifts/areas.
• Ensure incomplete records/charts are returned to nursing service for correction.
• Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing
• Follow established policies and procedures for the medical records section.
• Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
• Maintain a record of authorized information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
• Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
• Index medical records as directed by the medical records consultant.
• Maintain various registries as directed including register for admission and discharge of residents.
• Type reports for physicians as necessary.
• Collect charts, assemble them in proper order, and inspect them for competition.
• Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
• Assist in admission, transfer and discharge procedures as necessary.
• Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.).
• Assure that medical records taken from the department are signed in upon return to the department.
• File active and inactive records in accordance with established policies.
• Index medical records as directed.
• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of the Medical Records Clerk.

Other related duties and responsibilities that may become necessary or appropriate to meet the administrative

Needs of this facility.

Educational Requirements:

Must possess, as a minimum, a high school diploma.