Hospice Medical Records Clerk
- Maintains and updates patient files in EMR.
- Completes chart admission audit and communicates issues/problems to the Clinical Director.
- Inputs/updates into current software system any information or changes relating to clinical status, insurance, level of care, staff assignment or discharge.
- Scans and files all clinical data, hand signed orders and consents into patient records.
- Ensures plan of care/comprehensive assessment update/recertification are opened in a timely manner to allow staff to document their summaries prior to IDG team meeting.
- Tracks certification statements/POC/CS recertification’s and physician orders after RN emails to med records. Run unresolved order reports from admin console weekly to track unsigned orders.
- Maintains patient on-call book.
- Contacts physician office, hospital or nursing facility in a timely manner in order to obtain current information, signatures or any other information pertinent to the patient’s admission and their hospice chart.
- Assists as needed with providing information necessary for annual report and other patient data which may be requested.
- Receives visit logs from all staff.
- Compares visit log to contact visit report weekly.
- May assist with tracking and ordering durable medical equipment (DME) and medical supplies.
- Participates in Quality Assessment and Performance Improvement activities.
- If requested, participates in team meeting and is responsible for ensuring all documentation and charts are present as requested at team meeting.
- Responsible to maintain the team meeting sign-in sheet, and ensures that the team problem list is attached.
- Responsible for closing any paper records: clinical/bereavement charts, and preparing charts beyond thirteen (13) months so that they may be moved to off-site storage.
- Communicates with the Clinical Director in order that the charts are sent to off-site storage.
- Type’s letters, reports and other materials as requested.
- Answers the telephone in professional manner and channels the call accordingly.
- Interacts with other disciplines as needed to ensure support.
- Completes all other duties as assigned/requested.
- High school graduate or equivalent.
- One (1) year medical records experience, preferably in home health or similar operation.
- Positive interpersonal skills and good organizational skills.
- Is flexible, cooperative and self-directed in fulfilling roles.
- Ability to function as a member of an integrated healthcare work team.
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