Medical Records Clerk

Job Summary:

Maintains all documentation of patient records including but not limited to admissions, service provided and discharges. Manages processes for monitoring the accuracy and completeness of the EMR and ensuring the security and confidentiality of the records through the use of the required safe guards. Knowledgeable in all aspects of Agency policy and services.

Duties and Responsibilities:

Prints 485’s, physician orders and other clinical documentation for both Medical Surgical and Hospice

Sends documentation/orders to physicians via fax, mailings and or/uploads into Doc Center

Checks in received signed orders in Document Manager

Tracks to ensure signed physician orders are received by the agency according to standard (14-30 days), (Runs Outstanding report tracking. Runs Incomplete report 5 day window of start of care date for Certification/recertification report , CTI’s, Hospice Certifications/recertification’s, Hospice Face to Face

Follows up with the physician office for orders not received within agency guideline and documents call in episode note.

Notifies coordinator after two attempts to obtain orders, if unsuccessful.

Runs Outstanding Report for both Med Surgical and Hospice documents.

Identifies any changes/discrepancies in physician demographics, i.e., address, phone number. Notifies manager of finance to update physicians demographics

Identifies discrepancies on all orders of start of care date, diagnosis codes, verification of data corruption of clinician’s authorship

Makes correction to the system and documents changes in episode note.

Obtains documentation from medical record as needed.

Problem solves incorrect or incomplete information to ensure receipt of signed orders.

Runs and reviews system reports to manage document tracking.

Documents any privacy issues according to agency guidelines.

Identifies trends related to incomplete/inaccurate documents and reports same to coordinator.

Reviews designated vendor reports( McBee) report to process certifications, recertification’s

Notifies clinician to lock documents

Receives faxes and mail from physicians’ offices and any clinical paperwork that pertains to medical records

Sorts received information.

Obtains correct medical record.

Scans documentation into correct medical record episode (admission identifier)

Review MOLST forms for completeness and send to provider for signature

Send IDG Notes to designated provider by fax, mail or portal

Submits designated record requests to vendor( Sharecare) for processing. Documents the required elements in the EMR

Retrieves required documents for regulatory and other agencies as needed

Check that consents are on file for all patients. Notifies admit clinician and manager if consent is missing.

Cross train to answer reception calls from front desk and overhead telephone bell assistance

Assists in development of agency medical records education

Assist in the development of agency processes and procedures.

Requirements:

High school diploma or equivalent; with one year of related experience preferred.

Medical terminology, basic/intermediate skills using Microsoft Office applications; specifically: Excel, Word, Access and Outlook.

Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, and our Wellness Center, are trusted organizations fueling the latest advances in medical research, attracting the nation’s top specialty-trained doctors, and honing renowned services and innovative programs to engage in the important discussions people need to have about their health.

Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.

EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status

Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.