Medical Records Clerk

DISTINGUISHING FEATURES OF THE CLASS: An employee in this position is responsible for maintenance of the medical records of the Nursing Home or other health-related facility.  The duties involve important clerical work with responsibility for the assembly and maintenance of medical records and may be performed on an alpha/numeric keyboard.  The work is performed under the general supervision of a Medical Records Technician or other higher level Supervisor.  Supervision of other clerical staff is not normally a function of this position but may be required.  Does related work, as required.

TYPICAL WORK ACTIVITIES:
Assembles, analyzes, files and types medical records;
Reviews patients' records for completeness and accuracy according to established  standards;
Codes diagnoses, operations and special treatments according to recognized classification system;
Indexes and cross indexes records of diagnosis, operations, etc;
Assists medical or administrative staff in selecting and collating of records for medical research;
Abstracts medical records for special reports;
Catalogs medical records and controls their usage;
Transcribes operative reports, case histories, physical examination, discharge               summaries, consultations and minutes of the meetings of various committees of the medical staff;
May assist facility administrator in the preparation of periodic narrative and statistical presentations on the overall utilization of the facilities and programs;
May do statistical analysis of the performance of professional services using medical terminology and accepted nomenclature of classification of diseases and               operations.

FULL PERFORMANCE KNOWLEDGES, SKILLS, ABILITIES AND/OR PERSONAL CHARACTERISTICS: Working knowledge of the principles and practices involved in keeping medical records; ability to acquire a knowledge of technical medical terminology and usage; ability to establish good working relationships with physicians and other staff members; ability to type at an average rate of speed; ability to maintain confidential information as such; good judgment; thoroughness; dependability; tact; courtesy.

The physical demands described here are representative of those that must be met
by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit, use hands to finger, handle, or feel objects, tools, or controls; and reach with hands and arms.  The employee is required to walk, talk or hear.

The employee must occasionally lift and/or move up to 25 pounds.  Specific vision abilities required by this job include close vision and the ability to adjust focus.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually quiet.

MINIMUM QUALIFICATIONS:  Graduation from high school or possession of an equivalency diploma, including or supplemented by a course or experience in typing, AND EITHER:

1. An Associates Degree in Secretarial Science which includes coursework  in Medical Procedures, and Medical Terminology;
   OR:

2.   Two years of full-time, paid clerical experience in the medical or related fields;
   OR:

3. An equivalent combination of training and experience as defined by 1 or 2 above.        

Part-time experience will be pro-rated.