Medical Records Clerk jobs in Nebraska

Description

Lexington Regional Health Center

Title: Health Information Management Clerk

Effective Date: August 14, 2020

Supervisor: Director of Health Information Management

Department: Health Information Management

FLSA Status: Non-Exempt

Principle duties and responsibilities

1. Prepare charts for scanning and scan charts into electronic medical record system, sorting charts by documents and placing them in chronological order.
   
2. Review medical records for completeness. This includes ensuring all necessary documentation is completed and all required fields have been signed. Electronic deficiencies are applied when necessary.
   
3. Respond to requests for copies of protected health information in accordance with HIPAA privacy regulations. This includes the ability to analyze authorizations for HIPAA compliance and a working knowledge of what medium to release records on.
   
4. Answer main office telephone.
   
5. Collect and enter data for birth certificates.
   
6. Collect and enter data for death certificates.
   
7. Work in collaboration with other Health Information Management employees.
   
8. Abstract information from the medical record for chart review.
9. Monitor deficiencies and notify visiting specialists if they have deficiencies for completion.
10. Ensure patients and visitors follow current infection control guidelines.
    
11. Responsible for ensuring the environment meets appropriate governing body standards.
    
12. Duties that could include blood exposure and risk to bloodborne pathogens (eg: lacerations, handling of blood-contaminated items, etc.)
    
13. Maintains patient and staff safety through the use of patient safety tools (Teamstepps, Just Culture, etc.).
14. Regular attendance at the assigned work location is required.
    
15. Performs all other duties as assigned.

Minimum knowledge, skills, and abilities

1. Ability to use standard office equipment and computer software proficiently. Ability to read, analyze, and interpret reports, general business directives, policy and procedure statements, and governmental regulations. This is typically acquired through the completion of a high school diploma or equivalent.
   
2. At least one year of experience in the health information management field is preferred. This ensures a working knowledge of the parts of a medical record and the rules and regulations imposed on the health information management field of health care.
   
3. Medical terminology knowledge preferred.
4. Basic Life Support certification via American Heart Association required within six months of hire.
   
5. Ability to complete reports and correspondence at a professional level.
   
6. Ability to maintain strict confidentiality with regard to protected and sensitive information.
   
7. Ability to solve problems independently and confidently by applying analytical and logical thinking.
   
8. Ability to immediately respond to common inquiries and complaints from patients, employees and regulatory agencies.
9. Ability to effectively communicate with individuals from diverse backgrounds.
10. Ability to effectively organize and present information and respond to questions from employees and external groups of varying sizes.
11. Successful completion of required knowledge and training of standard precaution protocols and when to apply during principle duties and responsibilities.

Working conditions

1. Works in a normal office environment, well lighted and ventilated with minimal exposure to excessive noise, dust, temperature, etc.
   
2. Subject to frequent interruptions.
   
3. Requires auditory ability sufficient to hear the telephone with typical hearing-impaired enhancements and to hear normal conversations typical in an office setting.
   
4. Requires vision sufficient enough to read a computer screen with typical vision-impaired enhancements and to read entries made into the medical record.
   
5. Requires significant time at a desk both writing and on a computer, up to 90% of work time. Requires fine motor coordination 70% of work time. Workers are required to transport up to 8 pound stacks of paper to be placed on various shelf heights, from 13 inches from floor, up to 73 inches from floor 5% of work time. Workers are required to remove a shred paper bag from its enclosure, which weighs up to 90 pounds, and requires 2 people to remove and transport the bag 15 feet; this is completed approximately 1 time per month.

Management responsibilities

1. None

Job description statements are intended to describe the general nature and level of work being performed by employees assigned to this job title. They are not intended to be a complete list of all responsibilities, duties, and skills required.