Medical Records Clerk

Department: CORRECTIONAL CARE UNIT

Reports To: UNIT ADMINISTRATOR

Position Summary:Performs specialized clerical work in obtaining, recording and maintaining medical information. Provides medical records to the clinics and at sick call daily. Transcribes medical records and performs general clerical duties.

Qualifications:

• Education: High School graduate or equivalent.
• Personal Job-Related Skills: Typing speed of 45 wpm, operation of ten key adding machine/calculator. Familiar with operating personal computers and knowledge of general clerical duties and office procedures. Familiar with operating computers and Electronic Medical Records Systems.
• Licensure, Registry or Certification: None Required
• Experience:

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``` - Prior Work experience: Three year's work experience in full time employment including clerical duties as filing, posting, record verification and transcription or one year as a Medical Records Clerk in a health related facility, including transcription work preferred. - Technical Training: none required.

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``` - Physical and Mental Requirements: Duties of the position require intermittent walking, sitting, and standing. Some bending, stooping, and reaching is required with the lifting of items up to a weight of 40 pounds. The ability to comprehend and follow routine written and verbal instructions or directions.

Duties, Responsibilities, and Skills:

Performs Medical Records Duties:

• Places written and printed medical information into individual medical records in accordance with unit policy and procedure.
• Files and retrieves medical records in accordance with unit policy and procedure.
• Processes records of all inmates, incoming and outgoing, including clinic emergency room.
• Records and assures timely receipt of medical records.
• Assists with retrieving medical records for various clinics and with handling other requests for medical records in accordance with unit policy and procedure.
• Assists individual inmates requesting to review their medical records.
• Properly obtains consent for the release of medical information from individual inmates.
• Properly obtains consent to request medical information from free world facilities regarding individual inmates.

Performs Transcription Duties:

• Transcribes medical data from recorded dictation.
• Proofreads to ensure the correct spelling of medical terms and other reference material and makes correction of material, punctuation and grammar in the transcribed reports without changing the meaning.
• Follows the specified format for each type of report.
• Verifies the dictator, inmate name, record number and the dictation transcription date and time of each transcribed report.

Performs General Clerical Duties:

• Performs routine clerical tasks, including sorting and filing of loose reports and other documents.
• Assists authorized medical, security, education and administrative personnel with medical record information required to process lay ins housing assignments, medical classification, work restrictions, ect.
• Assists in the preparation of technical daily and monthly statistical reports generated in the unit medical department.
• Prepares and maintains various written reports and logs.
• Answers the telephone, takes messages and communicates messages to the appropriate person.

Other Significant Requirements:

1. Maintain HIPAA required and all other confidentiality while working with confidential matters on a daily basis.
2. Follow all policies and procedures set forth by Mitchell County Hospital District.
3. Provide service direct to patients while maintaining a positive customer relations atmosphere.
4. Other duties, as assigned by supervisor.

Work Schedule:

• Monday - Friday 7:00 am to 3:30 m
• 30 min lunch