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Medical Records Clerk

Job Type : Temp/Contract
Job Industry : Healthcare - Health Services

Job Description :

Purpose of Your Job Description

Under the supervision of the Brandman Centers for Senior Care (BCSC) Center Manager maintain medical records in accordance with federal and state guidelines and the established policies and procedures of BCSC.


Delegation of Authority

As the Medical Records Assistant, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.


Job Functions

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.


Administrative Functions                                                                                                                                             

·       Completes process of collecting, scanning, and uploading documents from all BCSC departments into the EMR on a daily basis.

·       Develops and maintains procedures that govern BCSC medical records functions.

·       Reviews BCSC medical records policies and procedures, at least annually, and makes recommendations to the Medical Records Coordinator.

·       Organizes BCSC medical records functions in accordance with established policies and procedures.

·       Assists the Medical Records Coordinator with orienting BCSC staff to medical records policies and procedures.

·       Responds to inquiries concerning medical records via telephone and e-mail.

·       Creates an index of medical records and assembles charts and electronic records.

·       In coordination with department supervisors, establishes procedures to assure records are properly completed and signed.

·       Ensures confidentiality of medical records and establishes procedures to assure paper medical records do not leave BCSC except as authorized.

·       In coordination with the Medical Records Coordinator, creates training schedule for all incoming employees and retraining classes for current employees. Train staff on how to use the electronic medical records system and ensure appropriate staff are given access to medical records.

·       Retrieves medical records when requested by authorized personnel and government agencies.

·       Maintains record of participant enrollment and disenrollment from BCSC.

·       As authorized by a participant or legal representative in a written consent, provides medical records to a receiving healthcare provider upon participant disenrollment from BCSC.

·       Collects record of participant admission to and/or discharge from a long-term care facility, hospital or supportive housing.

·       Collects and assembles medical records for committee review as requested and prepares reports for staff and committees as directed.

·       Word processes and types reports and prepares written correspondence.

·       Files active and inactive records in accordance with established policies and procedures.

·       Maintains all medical records per state and federal regulations requirements.

·       Consistently meets or exceeds BCSC target for productivity.

·       Continually seeks better ways for delivering services and communication with participants.

·       Consistently meets or exceeds BCSC customer services targets.

·       Demonstrates respect for and promotes participant right including dignity, self-determination, access to care, confidentiality and independence.

·       Effectively collaborates with staff peers and contractors to meet BCSC goals and further success.

·       Complies with all policy and procedures of BCSC.

·       Demonstrates proficiency in delivering age-specific care.

·       Consistently meets or exceeds BCSC quality assessment and performance improvement targets.

·       Completes other duties as assigned.


Personnel Functions                                                                                                                                                    

·       ATTENDANCE/ABSENTEEISM – Demonstrates regular attendance consistent with BCSC policies and guidelines.    

·       PUNCTUALITY/TARDINESS – Reports to work on time and prepared. Returns from meals and rest breaks within established policy time period frames.                                                                                                                               

·       COMMUNICATION – Ability to present ideas and thoughts in a direct, professional manner, both orally and in writing. Uses positive facial expressions and body language speaking clearly and slowly enough to be understood. Communicates well with staff, colleagues, and senior management. Refrains from negative commentary.                                                                                                

·       INITIATIVE – Soundly assertive in thoughts and actions; takes responsibility, makes efforts in the face of obstacles. Demonstrates leadership qualities.                                                                                                                                        

·       JUDGMENT – Displays well-balanced thinking, capacity to reach decisions quickly and accurately when necessary. Demonstrates tact and diploma cy when handling difficult situations or complaining clients.                                                                        

·       COOPERATION – Ability and willingness to work with others; promotes teamwork; demonstrates good rapport and cooperative working relationship with all staff members, responding with concern and cooperation. Works at maintaining a positive relationship wit other individuals and departments requiring frequent interaction.                                                                       

·       ADAPTABILITY – Willingness to work jointly with others, willingness to accept new ideas and suggestions. Capacity to adapt to new methods of conditions, capacity to be trained.                                                                                                   

·       DEPENDABILITY – Ability to follow directions and complete assigned responsibilities on time. Follows through on assignments to conclusion.                                                                                                                                                 

·       FLEXIBILITY – Ability to accept change, work multiple tasks simultaneously, and absorb and accept alternate assignments as necessary. Ability to re-prioritize as necessary when confronted with challenges or obstacles.                                    

·       PROBLEM SOLVING - Resolves problems and concerns in appropriate manner, following the proper chain of command.    

·       PARTICIPANT/EMPLOYEE RELATIONS – Is courteous and attentive to participants, employees, families, visitors, and other individuals with whom they may come in contact. Always greets staff/family/visitors in a courteous, professional manner responding with empathy when appropriate using positive interpersonal skills. Other employees have confidence in employee.                                                                                               

·       ATTITUDE – Shows interest and enthusiasm for job and organization. Effort to achieve organization and department objectives.                                                                                                                                                      

·       JOB KNOWLDEGE – Gets to the root of normal problems. Has understanding of job related functions and understanding of full job requirements. Makes effort to keep skills current.                                                                                                         

·       USE OF TIME – Is able to organize daily activity and complete assigned tasks in a reasonable amount of time.  

·       APPEARANCE – Is neat, well groomed and presents an appropriate use of BCSC dress code (including wearing a name badge.                                                                                                    


Staff Development Functions

·       Meets with department managers as needed and conducts/participate in in-service classes and training supervisory level training programs.                                                                                                                                                                                                                                 

·       Meets with departments as needed and conducts/participate in in-service classes and training programs.                         

·       Attends and participates in workshops, seminars, etc., to keep abreast of current changes in the long-term care field, as well as to maintain a professional status.                                                                                                                        

·       Attends and participate in annual in-service training programs for hazard communication, TB management, and bloodborne pathogens standard.                                                                                                                                       



Participants’ Rights Functions                                                                                                                                  

·       Maintain confidentiality of all participant information.                                                                                                    

·       Ensure the participants right to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are well established and maintained at all times.

Working Conditions

·       Works in office area(s) as well as throughout the program service area (i.e., nursing office and program areas. .

·       Moves intermittently during working hours.

·       Is subject to frequent interruptions.

·       Is involved with participants, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.

·       Is subject to hostile and emotionally upset participants, family members, personnel, and visitors.

·       Communicates with the medical staff, nursing personnel, and other department staff.

·       Works beyond normal working hours and on weekends and holidays when necessary.

·       Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).

·       Attends and participates in continuing educational programs.

·       Is subject to injury from falls, burns from equipment, odors, etc., throughout the work day, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.

·       Is subject to exposure to infections waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.

·       May be subject to the handling of and exposure to hazardous chemicals.



  • Degrees and diplomas: High school diploma.  Bachelor’s Degree preferred but not required.

·       Certificates, licenses: Verification of completion of CPR (BLS) and first aid training. Background clearance. TB screening and successful completion of a health examination by a health care provider is required for employment.

  • Experience: Qualified professional in the field of medical records with demonstrated or potential competence in working with healthcare staff. Three years of experience in the medical records field, or an equivalent combination of education and experience.

  • Skills/Aptitudes: Must be able to word process proficiently, use dictation equipment and have a working knowledge of medical terminology. Ability to work independently and to interact with an Interdisciplinary Team. Good organizational skills. Ability to handle complex interpersonal situations.




Specific Requirements

·       Must be able to read, write, speak, and understand the English language.

·       Must possess the ability to make independent decisions when circumstances warrant such action.

·       Must possess the ability to deal tactfully with personnel, participants, visitors and the general public.

·       Must be knowledgeable of medical terminology, laws, and regulations as they pertain to long‑term care.

·       Must possess the ability to work harmoniously with other personnel.

·       Must possess the ability to minimize waste of supplies, misuse of equipment, etc.

·       Must be able to follow written and oral instructions.

·       Be knowledgeable in computers, data input and output.

·       Must be able to relate information concerning a participant’s condition.

·       Must not pose a direct threat to the health or safety of other individuals in the workplace.



Physical and Sensory Requirements

(With or Without the Aid of Mechanical Devices)

·       Must be able to move intermittently throughout the work day.

·       Must be able to speak and write the English language in an understandable manner.

·       Must be able to cope with the mental and emotional stress of the position.

·       Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.

·       Must function independently, have personal integrity, have flexibility, and the ability to work effectively with other personnel.

·       Must meet the general health requirements set forth by the policies of this facility which include a medical and physical examination.

·       Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet.

·       May be necessary to assist in the evacuation of participants during emergency situations.

Required Qualifications :
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