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Job Overview

A medical records clerk is responsible for a variety of tasks including collecting consumer information, issuing medical files, filing medical records, and processing consumer admissions and discharge papers. They ensure medical records are maintained in a manner compliance with ethical, legal and regulatory requirements of the medical services system.

This is a PT position for about 20 hours per week.

Responsibilities and Duties

• Gathers consumer information by collecting demographic information via interviews with the program supervisors, case coordinators, consumer, or their family (as needed).
• Maintains master consumer list by completing an assigned portion of the daily audit trail.
• Facilitate the flow of information in the medical record by creating, processing, and updating the medical record including but not limited to filing.
• Maintains record availability by uploading the medical record into the agency’s electronic health record.
• Keeps staff informed by communicating the availability of requested records.
• Provide oversight of the current medical records chart-out procedures.
• Maintains quality results by adhering to service guidelines and standards.
• Ensures compliance with established external and internal control procedures ve examining records, reports, operating practices and documentation
• Verifies compliance through comparison of documentation to established policies, procedures and regulations.
• Completes audits through hands-on, on-site review of consumer charts, office and preparing for Plan of Correction and follow -up.
• Appraises adequacy of internal control systems by completing audit checklists.
• Maintains internal control systems by updating audit programs and checklists, recommending new policies and procedures.
• Communicates audit findings by preparing reports (as requested); discussing and presenting findings to the Compliance team.
• Complies with federal, state, and local program requirements by studying existing and new legislation; enforcing adherence to requirements; advising management on needed actions.
• Prepares special audit and control reports by collecting, analyzing, and summarizing operating information and trends.
• Report critical concerns and problems to supervisor in a timely manner and actively seek supervisor’s input and assistance with resolving all matters.
• Maintain professional and technical knowledge by attending educational workshops; reviewing professional publications; establishing personal networks.
• Work with a team approach with other staff to ensure efficacy of care of ALL consumers.
• Attend staff meetings, panned in-service trainings and any other regular or assigned meetings.
• Contributes to team effort by accomplishing related results as needed.
• Perform any other job related duties assigned by the supervisor and/or director to maintain the continuity of care for consumers serviced and profitability of the agency.

Education/Qualifications/Experience

Completion of at least a high school diploma or equivalent
Minimum of 1 year experience working in a medical office setting
Experience with Medical Terminology
Must be at least 18 years of age, be able to read, write, understand, and follow directions, has no substantiated findings of abuse or neglect listed on NC Health Care Registry, and no criminal convictions.
Reporting skills, Administrative Writing Skills, Microsoft Office Skills, Managing Processes, Organization, Analyzing Information, Professionalism, Problem Solving, Supply Management, Inventory Control, Verbal Communication.

Training Requirements

Must complete CTS Health initial Orientation training
HIPPA, Consumers Rights, Confidentiality, CPI, First Aid, CPR, Blood Borne Pathogens, Workplace Violence, Case Management, Cultural Competency, Customer Service/Professionalism
Service Definition Trainings:
All related service definitions required