The Medical Records Clerk primarily compiles and maintains medical records of patients of health care delivery system to document patient condition and treatment.
Medical Records Director Requirements- Must be familiar with PCC (Point Click Care System)
- Fully vaccinated against COVID-19 including Booster shots
- Strong Organizational and Office Technology Skills
- Knowledge of HIPPA and Client Confidentiality Laws
- Proficient in Medical Terminology
- Comfortable in Collaborating with Healthcare Professionals
- Leadership skills
- Detail Oriented
Primary Medical Records Director Responsibilities- Complies with the facility's attendance policy requiring regular, reliable, and punctual attendance
- Maintains daily admission and discharge log for each resident
- Prepares charts for admission with chart order form in front of chart
- Checks charts on new admissions daily until all below required paperwork has been completed
- Prepares all charts with tabs following chart order sequence
- Assists with paperwork on new admissions
- Prepares all forms in the chart with resident identification information
- Assembles and audits discharged residents' records
- Prepares computer sheets on scheduled dates for physician recaps and inputs physicians' orders via the Medical Records Accu-Care computer system
- Operates computer to process, store, and retrieve health information
- Completes recaps on timeline agreed upon by Director of Nursing
- Completes audit schedule each day, week, and month
- Audits charts
- Participates in the Quality Assurance Program and Utilization Committee Meetings and passes CQI
- Follows up on all consultant/QA recommendations
- Utilizes medical records procedure manual as needed
- Responsible for maintaining up-to-day inventory of facility forms
- Attend mandated meetings: daily standup, weekly PPS, and monthly triple-check
- Performs other duties or functions as assigned by the Administrator
Other Responsibilities- Ability to pull multiple reports using PCC system
- Assists with paperwork on new admissions and discharges
- Utilizes medical records procedure manual as needed. Does daily audits as assign
- Prepares files, records and logs under the supervision of the Medical Records Designee
- Requires attention to detail, lots of uninterrupted time at a desk with computer, and reliability
- Employees must be able to maintain consistent attendance
- Other duties may be assigned
PAY SCALE:Depending on a number of factors, including, but not limited to location, regularly scheduled work shift, knowledge, skills, experience, and expertise.
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