Medical Records Clerk

Assists the clinical department with recordkeeping, chart audits, statistical reports, typing, and general medical records support. Responsible for entering new admissions, changes in level of care, discharges, contact visits, physician orders, signature dates, and face-to-face completion dates into the electronic medical record. Also supports supply ordering and other administrative tasks as needed.

Essential Responsibilities

• Maintain and update patient files in the EMR.
• Complete chart admission audits and communicate issues to the Clinical Director.
• Enter and update clinical status, insurance, level of care, staff assignment, and discharge information in the software system.
• Scan and file clinical data, signed orders, and consents into patient records.
• Ensure plan of care, assessment updates, and recertifications are opened in a timely manner.
• Track certification statements, POC/CS recertifications, and physician orders; run unresolved order reports weekly.
• Maintain the patient on-call book.
• Contact physician offices, hospitals, and nursing facilities to obtain information and signatures related to admissions and hospice charts.
• Assist with information needed for annual reports and other patient data requests.
• Receive and compare visit logs and contact visit reports weekly.
• Assist with tracking and ordering DME and medical supplies.
• Participate in quality assessment and performance improvement activities.
• Ensure required documentation and charts are available for team meetings.
• Maintain the team meeting sign-in sheet and attach the team problem list.
• Close paper records and prepare charts for off-site storage.
• Type letters, reports, and other materials as requested.
• Answer the telephone in a professional manner and route calls appropriately.
• Complete other duties as assigned.