Medical Records Clerk

Maintains all documentation of patient records including but not limited to admissions, services 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 safeguards. 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, and 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 guidelines 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, and notifies manager of finance to update physician demographics. Identifies discrepancies on all orders of start of care date, diagnosis codes, verification of data corruption of clinician’s authorship. Makes corrections to the system and documents changes in episode note. Obtains documentation from medical records 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) to process certifications and recertifications. 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. Reviews MOLST forms for completeness and sends to provider for signature. Sends IDG Notes to designated provider by fax, mail, or portal. Submits designated record requests to vendor (Sharecare) for processing and documents the required elements in the EMR. Retrieves required documents for regulatory and other agencies as needed. Checks that consents are on file for all patients and notifies admit clinician and manager if consent is missing. Cross trains to answer reception calls from front desk and overhead telephone bell assistance. Assists in development of agency medical records education. Assists 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.

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