Medical Records Clerk
A Medical Records Clerk organizes and maintains health information data, ensuring its accuracy, accessibility, and security in both paper and electronic systems.
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Sample Job Descriptions for Medical Records Clerk
Below are the some sample job descriptions for the different experience levels, where you can find the summary of the role, required skills, qualifications, and responsibilities.
Junior (0-2 years of experience)
Summary of the Role
The Medical Records Clerk is responsible for organizing, maintaining, and ensuring the accuracy of all patient records and data. This role requires an individual who is detail-oriented, can maintain confidentiality, and efficiently handle paperwork and electronic health records.
Required Skills
- Attention to detail
- Organizational skills
- Communication skills
- Ability to maintain confidentiality
- Basic understanding of medical terminology
- Proficiency in computer systems and EHR software
Qualifications
- High school diploma or GED equivalent.
- Familiarity with medical terminology and HIPAA regulations.
- Basic computer skills and experience with electronic health records (EHR) systems.
Responsibilities
- Organize and manage patients' health information data.
- Ensure paperwork is properly filled out and filed.
- Maintain digital and physical healthcare records.
- Verify accuracy and accessibility of files.
- Protect patient confidentiality according to HIPAA regulations.
- Assist with departmental audits and information requests.
- Use electronic health record (EHR) systems to access and update records.
Intermediate (2-5 years of experience)
Summary of the Role
As a Medical Records Clerk, you will be responsible for organizing, maintaining, and ensuring the accuracy of all medical records within a healthcare facility. Your role is crucial in ensuring that healthcare professionals have access to complete and up-to-date patient information to provide the best care possible.
Required Skills
- Strong organizational and time management skills.
- Attention to detail and accuracy.
- Ability to maintain confidentiality.
- Proficiency in data entry and management.
- Good communication and interpersonal skills.
- Technical skills including proficiency with EHR software.
Qualifications
- Associate's or bachelor's degree in Health Information Management or related field preferred.
- Certification as a Registered Health Information Technician (RHIT) or similar.
- 2-5 years of experience working as a medical records clerk or in a similar role.
- Knowledge of medical terminology, coding, and medical record laws and practices.
- Experience with electronic health record (EHR) systems.
- Familiarity with privacy laws and regulations such as HIPAA.
Responsibilities
- Organize and manage patients' health information data.
- Ensure medical records are maintained in a confidential, secure, complete, and accurate manner.
- Retrieve and deliver medical records to healthcare professionals as required.
- Convert paper records to electronic systems if necessary.
- Review records for completeness, accuracy, and compliance with regulations.
- Process admission and discharge records accurately and timely.
- Utilize electronic health records (EHR) systems to enter, retrieve, and analyze patient data.
- Assist with audits and quality assurance processes.
Senior (5+ years of experience)
Summary of the Role
As a Senior Medical Records Clerk, you will play a critical role in managing and safeguarding the medical records of our healthcare facility. Your extensive experience will be vital in ensuring the accuracy, confidentiality, and security of patient information in compliance with hospital policies and legal requirements.
Required Skills
- Highly organized with attention to detail.
- Effective communication and interpersonal skills.
- Strong leadership and team management abilities.
- Proficient in the use of electronic health record systems.
- Problem-solving skills and ability to handle multiple tasks.
- Knowledgeable in data privacy and security protocols.
Qualifications
- Proven experience of 5+ years as a medical records clerk or similar role.
- In-depth knowledge of medical terminology and healthcare operations.
- Familiarity with electronic health record (EHR) systems and medical software.
- Strong understanding of HIPAA regulations and compliance requirements.
- Excellent organizational and leadership skills.
- Ability to maintain confidentiality regarding patient health information.
Responsibilities
- Oversee the daily operations of the medical records department.
- Ensure accurate maintenance, storage, and retrieval of patient health records.
- Train and supervise junior clerks in managing medical records.
- Conduct regular audits to ensure compliance with legal and hospital policies.
- Collaborate with healthcare providers to ensure timely and accurate documentation.
- Implement and oversee electronic health record systems.
- Respond to requests for medical records and information from authorized individuals.
- Develop and maintain departmental policies and procedures.
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