Medical Records Clerk
Category:
Health Information ManagementDepartment:
HIM
Description:
SUMMARY: To assemble the discharged patient’s medical records confirming a complete medical record. Files any loose reports received after discharge to the previously assembled record. Assists with verification of provider completion of deficiencies and updates hospital EHR accordingly.
Key Responsibilities
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Incomplete Record Resolution – Partner with physicians and APPs daily to address dictation, signature, and documentation deficiencies; track progress and escalate as needed.
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Birth Certificate Filing – Prepare and submit state‑mandated electronic birth certificates, verifying demographic and clinical data for accuracy.
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Chart Analysis – Perform post‑discharge reviews for Sleep Studies, Respiratory Therapy, and Interventional Radiology encounters, flagging missing elements and ensuring compliance with CMS standards.
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EKG Routing & Reporting
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Route all outpatient EKG tracings to the on‑call cardiologist for interpretation.
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Compile and report the total number of EKGs read to Professional Fee Billing and Accounts Payable staff each week and month.
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Release of Information Support – Provide back‑up coverage for ROI requests, including validating authorizations, pulling records, and documenting disclosures.
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Other HIM Duties – Scan, index, and QC paper documents; answer department phones; and assist with special projects as assigned.
Qualifications
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High School diploma or equivalent required; coursework or credential in Health Information Technology (RHIT, CPC, etc.) preferred.
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1+ year in a hospital HIM or medical office setting strongly preferred.
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Working knowledge of electronic health record (EHR) systems and medical terminology.
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Familiarity with HIPAA privacy regulations and Joint Commission record standards.
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Proficient in Microsoft Office; ability to build basic tracking spreadsheets.
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Excellent attention to detail, time‑management, and customer‑service skills when interacting with providers and patients.
Closing:
Open until filled