PRIMARY HEALTH CARE

JOB TITLE:PAY GRADE: 3

Medical Records ClerkFLSA Non-Exempt

GENERAL DESCRIPTION:

Works under the general supervision of the Clinic Director. Responsibilities include retrieving and filing medical records, maintaining the order of the medical record, filing reports and documents in the medical record, and receiving and processing requests for information from the medical record. Assists Clinic Director with HIPAA activities.

CHARACTERISTIC DUTIES:

  1. Retrieves and files patient medical records as designated in policies and procedures.
  2. Maintains the order of the medical record as designated in policies and procedures.
  3. Files loose reports in the medical record in a timely fashion.
  4. Analyzes the medical record for completeness.
  5. Works with clinic staff to assure that the flow of medical record documentation is timely and in accordance with organizational procedures.
  6. Receives and processes requests for information in accordance with organizational policies and procedures.
  7. Assures timely collection of charge tickets with distribution to the Billing Department.
  8. Assists in the distribution and tracking of HIPAA Privacy Notices.
  9. Assists staff with requests for patient information such as telephone numbers, addresses, etc.
  10. Keeps Clinic Director and appropriate staff abreast of compliance issues and completes all documentation requirements accurately and concisely.
  11. Assists in gathering information for performance improvement functions, including medical record reviews, peer review, etc.
  12. Serves as back up for the clinic office specialist function including performance of registration and scheduling functions.
  13. Demonstrates awareness and sensitivity to client’s rights and functions.
  14. Demonstrates an awareness of self-responsibility and accountability; utilizes critical thinking and decision-making. Must be flexible and able to work independently.
  15. Demonstrates effective communication methods and skills, using lines of authority appropriately.
  16. Attend weekly department meetings, in-service programs pertinent to own program
  17. Performs other related duties as assigned.

PERFORMANCE STANDARDS:

  1. Demonstrates ability to analyze medical records for completeness within 24 hours of visit, 95% of the time.
  2. Demonstrates ability to file dictated reports into the patient medical record within 2 days of visit, 95% of the time.
  3. Demonstrates the ability to file loose reports within five working days of receipt, 95% of the time.
  4. Demonstrates ability to process release of information requests within 5 working days, 95% of the time.
  5. Demonstrates the ability to process HIPAA privacy notices (mailed out) within 24 hours of the encounter, 95% of the time.
  6. Demonstrates commitment to professional growth and competence. This will be demonstrated by the completion and documentation of all competencies, department specific skills, and in-service training, 95% of the time.
  7. Demonstrates consistent ability to meet Personal Performance Summary Standards.

MINIMUM QUALIFICATIONS:

  1. High School diploma or GED
  2. One year work experience in a medical office setting
  3. Ability to consistently meet the department work schedule as designated

PREFERRED QUALIFICATIONS:

  1. One year medical record experience
  2. Knowledge of medical terminology
  3. Bilingual (Spanish)
  4. Experience in community health center

PHYSICAL DEMANDS:

SEDENTARY (Requires lifting 10lbs., carrying small objects)_____

LIGHT (Requires lifting 20 lbs., with frequent carrying of up to 20 lbs.)_____

MEDIUM (Requires lifting 50 lbs., with frequent carrying of up to 25 lbs.)__X__

HEAVY (Requires lifting 100lbs., with frequent carrying of up to 50 lbs.)_____

VERY HEAVY (Requires lifting over 100 lbs., such as moving furniture)_____

CODES:C = Continuously,F = Frequently, O = Occasionally, R = Rarely

(70% or more) (40-70%) (15-40%) (less than 15%)

Standing / F / Reaching / O / Crawling / R
Sitting / F / Handling / O / Bending / O
Walking / F / Fine Dexterity / O / Twisting / R
Lifting / O / Kneeling / R / Climbing / R
Carrying / O / Crouching / R / Balancing / R
Pushing/Pulling / O / Foot Controls / O / Vision / C
Hearing / C / Talking / C / Other

WORKING ENVIRONMENT

Definitions for OSHA working environment are: Category I – Involves routine exposure to blood or body fluids, Category II – Involves possible exposure to blood or body fluids, Category III – Involves no exposure.

OSHA Category for this position is Category __III____.

SUPERVISION:

Received: Clinic Director

Exercised: None

AGE OF THOSE SERVED IN THE ASSIGNED SERVICE AREA (Please check those applicable)

__X_Neonate/ __X_Toddler/__X_School Age _X_Adolescent _X_Adult _X_Aging ____ Not

Infant Preschool Applicable

0-1 yr 1-5 yrs 6-12 yrs 13-18 yrs 19-65 yrs 66+ yrs

APPROVED BY: ______

Executive Director

______

Operations Director

Issued:4/2003

Reviewed:

Revised:6/2005

Disclaimer: The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified shall not be considered as a detailed description of all the work requirements that may be inherent in the position.

I have reviewed and received a copy of this job description.

______

Employee SignatureDate