EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

• High school diploma or equivalent required.
• Experience in quantitative medical record reviews preferred.

PURPOSE STATEMENT:

Perform clerical duties associated with obtaining, completing and maintaining a patient medical records.
Responsibilities:

ESSENTIAL FUNCTIONS:

• Sort, file and collate a variety of medical records and information such as progress notes, treatment plans, nursing/clinical notes and discharge summaries into the patient’s medical record.
• Create medical record files.
• Ensure medical records are complete, accurate and timely.
• Research lost or missing records/information in accordance with established procedures.
• Answer requests for medical records from outside agencies and third-party sponsorship.
• May communicate with transcriptionist or transcription vendor to resolve issues/errors regarding reports.
• Assist designated staff in locating records in the medical records department.
• Maintain accurate logs, card files, statistics and information release forms for providing medical record information.
• Ensure medical record is complete prior to filing/re-filing and accurately update log.
• Perform medical record audits.