Medical Records Clerk - Home Care organizes, files, and retrieves patient medical records for a home care office. Files various medical documentation, including patient notes, radiology reports, and lab results. Being a Medical Records Clerk - Home Care performs related clerical duties. May be responsible for clerical duties related to patient admission/discharge. Additionally, Medical Records Clerk - Home Care works with both paper-based systems and electronic medical records (EMR). Typically requires a high school diploma or its equivalent. Typically reports to a supervisor or manager. The Medical Records Clerk - Home Care possesses a moderate understanding of general aspects of the job. Works under the close direction of senior personnel in the functional area. May require 0-1 year of general work experience. (Copyright 2024 Salary.com)
This is a full-time position, Monday – Friday, 40 hours, 8a – 4p. Pay Range of $18-22/hr based on years of relevant experience.
Summary:
The primary role of the Unit Secretary/Medical Records Clerk is to assist the Nursing Department with nursing related tasks such as; booking transportation appointments, recording and charting of medical or administrative information, accompanying residents on appointments, filing, maintaining and properly storing medical records; ensuring that all records are complete and properly signed according to regulatory agency guidelines and company policy. This position requires the maintenance of all nursing supplies, such as ordering, stocking, and distribution.
Responsibilities:
· Record medical and administrative information in accordance with established charting and documentation policies and procedures.
· Maintain the Daily Census Report and submit to Nurse Supervisor.
· Maintain an up-to-date roster of residents.
· Completes timely, accurate filing of resident’s medical record overflow.
· Answer telephone, page calls, deliver messages to residents, etc., as necessary.
· Maintain a current listing of emergency phone numbers for units.
· Record appropriate resident identification data on designated medical records
· Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, legibility, etc., as directed.
· Record vital signs as directed.
· Forward new diet orders and/or diet changes to the Dietary Department.
· Keep nursing service personnel informed of residents’ appointments.
· Arrange for and making resident appointments and communicate all Medicare
· Part A with prior approval from Administration.
· Must Inspect resident records to ensure that they are in proper order; maintains accurate and complete records regarding admissions and discharging of residents; thins medical records as directed.
· Demonstrate the knowledge and skills necessary to carry out and perform assigned duties in the nursing department, and completes on-going competency requirements as required
· Must perform all assigned tasks in accordance with the Facility’s established policies and procedures and as instructed by the DNS, and/ or Administrator or as directed by supervisory staff.
Qualifications:
· High School diploma or equivalent, required.
· Maintain a current/active State of CT CNA certification
· Must have working knowledge (experience preferred) with various software programs such as WORD, OUTLOOK and EXCEL, as well as (experience preferred in) electronic medical records (EMR) systems.
· Must be able to speak, read and write the English language clearly and understandably.
· Must be able to follow written and oral instructions.
Compensation & Benefits:
· Generous salary, commensurate with experience
· Benefits program, includes health, dental, and vision insurance
· 401(k) Retirement program
· Shift Differentials
· Paid Holidays
· Excellent growth and advancement opportunities
· Collaborative work environment
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