Medical Records Clerk

POSITION: Medical Records Staff
STATUS: Non-Exempt; Full time
REPORTS TO: Medical Records Coordinator
SUPERVISES: None
DEPARTMENT: Clinic Operations Department, Medical Records Unit
OFFICIAL DUTY STATION: Los Feliz Health Center (1530 Hillhurst Avenue, Los Angeles, CA 90027)
 

BENEFITS:

• Public Service Loan Forgiveness
• 401(k) Retirement Plan
• Medical, Dental, and Vision Insurance
• 12 Paid Holidays
• Life Insurance, Short Term Disability, Accident Insurance, etc.
• Commuter Discount (Metro, Metrolink)
• Commuter and Ride Share
• Discounted Tickets

DUTIES AND RESPONSIBILITIES:

Focus on Patient Medical Records:

1. Ensures that all medical records are maintained appropriately and repairing any patient medical record that does not meet department standard.
2.  Ensures all medical records are secure, complete (ex. Master IM is generated and signed-off) and up to date at all times.
3.  Keeps patient medical records cabinets organized and secure at all times
4. Facilitates in the location of missing patient medical records
5. Prepares and reviews patient medical records 2 to 3 days prior to patient appointment schedule to ensure completeness.
6. Reviews all patient medical records prior to patient medical visit for accuracy and ensuring all labs, diagnostic testing and consultation reports are available and filed appropriately in the Electronic Health Record. This is not limited to providing accurate updates on information critical to patient care.  
7. Prepare and provide a paper progress note for care team to document the visit when there is computer system is down or there is a power outage. 
8. Maintain paper forms in a case where EHR system is down and unavailable.
9. Ensures that all documentation contained in patient medical record has appropriate label identifying the patient correctly.
10. Immediately notifies Medical Record Coordinator or Medical Record Lead if patient medical record has incorrect patient information identified in it.
11. Provides and tracks all assistance to all departments that require individual patient medical records for the completion of respective duties
12. Pulls charts as needed for special audits, peer review as required
13. Files accurately with a patient label of each of the following: lab and diagnostic results, referral forms, consultation reports, correspondence and patient returned mail.
14.  Answers all department calls regarding patient medical record questions and requests.
15. Responds and tracks all patient medical records request on appropriate department logs. 
16.  Controls internal and external medical records requests.  Assures completion of unemployment, disability, and release of medical & dental records requests.
17.  Facilitates patients with the request for patient medical records release to other facilities and for the patient’s own use. 
18. Create a tracking in i2iTrack when sending a request of the protected health information release to other providers/facilities and update the tracking upon the receipt of protected health information 
19.  End of day functions: ensures that all loose documents are reviewed and all forms are appropriately scanned and filed in correct document types in ICS/NextGen according to the ICS scanning guidelines. All forms scanned have patient label attached to clearly identify the correct patient.
20. Transfers and maintains records electronically by batch scanning, single scanning, importing, and indexing, referrals reports, et cetera
21. Ensures the appropriateness of forms used in electronic health record.
22. Utilizes and understands coordination of current practice management systems, Next Gen and InfoPoint in locating current and archived patient charts. 
23. Obtain consultation report and radiology report from other providers/facilities (via UMI, Renaissance Portal, etc.)  
24. Update and document the receipt of consultation report in the tracking system (i2iTrack) and EHR/NextGen
25. Check digital fax on daily basis

Focus on Patient Medical Record Archiving:

1.  Prepares patient medical records for appropriate archiving
2. Ensures documentation of all patient medical records that are deemed inactive through the current practice management system and moved to storage
3. Uses automated systems to verify, update, input, and retrieve patient information.

Focus on Teamwork:

1. As a team member of APHCV, each Medical Records Team Member respects and protects information regarding patients and other team members and abides by the rules of HIPAA ensuring all APHCV HIPAA policies and procedures are followed at all times.
2. Facilitate patient flow by working effectively and efficiently.
3.  Maintain open communication with all clinic staff and departments
4. Maintains a professional demeanor at all times with patients, providers and other department staff.
5.  Various other job related duties as assigned by supervisor.  
6. Job duties and responsibilities may be added, deleted, or changed at any time at the discretion of management, formally or informally either in writing or verbally

PERFORMANCE EXPECTATIONS:

1. Regular predictable attendance during clinic hours
2. Ability to work flexible and extended hours when scheduled and necessary for efficient department functioning
3. A strong understanding of computers, coding and health information concepts to ensure the development of continual quality improvement of health information system resources.
4. Collects and records all patient information accurately
5. Ensures all information is accurately identified in the correct patient medical record
6. Works efficiently, accurately and with minimum supervision
7. Must be well-organized, detail oriented and a self-starter
8. Able to follow directions and follow up on recommendation from supervisor
9. Ability to work with people of diverse cultural, educational, socio-economic and linguistic backgrounds
10. Performs multi-tasks in a fast pace environment
11. Proficiency in written and verbal English
12. Consistently and openly communicates with supervisor and all staff
13. Exceptional customer service skills
14. Computer proficiency; working knowledge of Microsoft Office applications, Access and all other systems used by APHCV
15. Demonstrates HIPAA knowledge
16. Goes through additional training and education on the job

SUMMARY:

Medical Records Operations assures the delivery of primary care services by ensuring timely availability of a complete, accurate, and up-to-date medical information for all APHCV patients at all APCHV service locations. Although Medical Records Unit is housed in APHCV Los Feliz Health Center, the Unit is responsible for the Medical Records Operations for the entire Medical Record Operations for all APHCV service locations in terms of quality, standard, and performance and implementation of policies and procedures.

The Medical Records Clerk makes significant contributions and participates in the on-going changes that make APHCV and its delivery teams successful and dynamic. He/she provides excellent customer service to patients with thorough standardized documentation of patient information. 
 

REQUIRED:

1. High School Diploma or GED
2. Some College preferred
3. Completion of Medical Terminology Course
4. Experience equivalent to one year working in medical office setting preferred.
5. Good communication skills and able to communicate in English and at least one Asian language or Spanish.
6. Ability to recognize different API languages by hearing
7. Excellent oral and written skills
8. Intermediate computer skills
9. Keyboarding (45 wpm); software management 
10. Medical Terminology
11. Customer-service oriented
12. Well organized, systematic, prompt
13. Able to quickly build and maintain rapport with patients and providers of differing backgrounds; team player
14. Correct grammar and spelling
15. 10 Key calculator
16. Must be able to lift up to 10 pounds and push up to 25 pounds (on wheels).
17. Must be able to hear staff on the phone and those who are served in-person, and speak clearly in order to communicate information to clients and staff.
18. Must be able to have vision that is adequate to read memos, a computer screen, personnel forms and clinical and administrative documents.
19. Must have high manual dexterity.
20. Must be able to reach above the shoulder level to work, must be able to bend, squat and sit, stand, stoop, crouching, reaching, kneeling, twisting/turning, fingering and feeling.
21. Must have an annual physical check-up yearly

HR Procedural Requirements:

1. Legal authorization to work in the United States 
2.  A valid California Driver’s license with clean records and access to insured automobile
3. Completion of APHCV Health Assessment Form
4. Completion of DOJ background check