Under general supervision, the Medical Records Clerk assists the Director of Nursing and/or Health Services Director in maintaining the facility's clinical record system. Reviews, audits and updates charts on paper and/or on computer, including physicians order sheets, medication sheets and treatment sheets and ADL sheets; processes admissions and discharges. Responsible for following standards of practice and facility policies and procedures to ensure complete, timely, and accurate medical records. Will manage all aspects of the medical patient record from admission to discharge. Also assists in implementing record procedures for the Clinical Records Unit. As a representative and team member of the company, this position is expected to present oneself in a manner that reflects professionalism and ensures resident satisfaction.

Qualifications

Education – High School Diploma or equivalent; Associates degree in Medical Record Technology preferred; Completion of classes in medical terminology and knowledge of HIPPA.
Experience/Training – Minimum of 6 months to one year of experience in a health related enterprise as medical records clerk; some mathematical skill; or any equivalent combination of training and experience which provides the required skills, knowledge and abilities.