MEDICAL RECORDS/WARD CLERK

Summary:
Under the general supervision of the Administrator, and in compliance with all applicable organizational policies, standards and regulatory requirements, the individual is responsible for maintaining medical records to document history, treatments and orders, and to identify, compile, abstract and code patient data using standard classification systems.
Essential Job Functions:
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Protects the security of medical records to ensure that confidentiality is maintained.
• Reviews records for completeness, accuracy and compliance with regulations.
• Compiles and maintains patients' medical records to document treatment, physician orders, nursing notes, etc.
• Enters data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer.
• Plans, develops, maintains, and operates a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.
• Identifies and compiles patient data using standard classification systems.
• Resolves/clarifies codes and diagnoses with conflicting, missing, or unclear information by consulting with the nursing facility staff or others to get additional information
• Purges records as per policy
• Orders & receives office supplies and medical forms, journals, books, etc.
• Participates in staff meetings and new employee orientation and training programs.
• Performs maintenance functions for the department computer system.
• Assists in maintaining and fostering customer relationships.
Qualifications:
• At least two years’ experience working in long-term care.
• Experience in computer operations required.
• Associate in Science degree in medical records preferred or certification as medical coder preferred.
• Must demonstrate the ability to read, write and speak English.
• Must demonstrate ability to work independently, without direct supervision, within established policies.
• Must have demonstrated effective skills both in writing and verbal communication.
• Must have effective interpersonal skills.
• Must be able and willing to travel to customers/facilities as needed.
Physical Requirements and Working Conditions:
Will meet all physical requirements of the position as identified by the facility policies and procedures
related to functional job analysis.
Other Duties:
Please note this job description is not designed to cover or contain comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.