Medical Records Clerk

Job Overview:

The HIM Medical Records Clerk/Scanner is responsible for collecting, verifying, scanning, indexing, and maintaining patient medical records. This role ensures documentation accuracy across systems while supporting compliance with hospital policies, regulatory requirements, and confidentiality standards.

Key Responsibilities

The following duties are representative of the position and are not intended to be an all-inclusive list. Additional responsibilities may be assigned as needed.

Document Collection & Distribution

• Retrieve paperwork daily from designated areas (front office, nursing stations, lab, radiology, physician offices).
• Distribute incomplete documentation (e.g., letters, reports) to appropriate providers and departments.

Night Report Review & Processing

• Review night reports for accuracy and completeness; save to designated network drive.
• Verify presence of History & Physical (H&P), including ER encounters when applicable.
• Update admission status (OBS, IP, SBS) for all patients.
• Confirm insurance information for SBS patients.
• Send required Medicaid/KanCare notifications at admission and discharge.

Daily Census (Sticker Sheet)

• Collect sticker sheets daily from nursing stations.
• Review for missing stickers and reconcile with patient lists.
• Add missing stickers as needed.
• Verify ER stickers match collected ER charts and analysis.
• Scan and email completed sheets to designated recipients.

iMedX Dictation Processing

• Verify patient and encounter details (Name, MRN, DOS, FIN).
• Ensure letters are on correct letterhead, scanned into charts, and routed for provider review/signature.
• Review operative notes for completeness: correct missing details, spelling, grammar, and transcription errors.
• Confirm imported documentation is visible in Cerner (PowerChart).

Scanning & Indexing

• Scan records into the EHR system in a timely manner.
• Ensure scanned document dates match originals.
• Verify required signatures are present prior to scanning.

Data Entry & Tracking

• Maintain logs (EKG, H&P, missing consents, nursing home patients, ED tracking).
• Perform chart analysis (ED, ambulatory surgery, inpatient, outpatient) to ensure completeness and compliance.
• Assist with time studies and reporting as needed.

Release of Information (ROI)

• Process medical record requests in accordance with HIPAA and facility policies.
• Log all ROI requests in departmental tracking spreadsheets.
• Handle requests submitted through Revenue Cycle (billing).

Equipment Maintenance

• Perform routine checks to ensure scanners and related equipment function properly.

Archiving

• Archive scanned records according to department procedures once current workload is complete.

Transfer Documentation

• Prepare transfer paperwork based on patient disposition:
  • EMTALA: Nurse completes form; provider signs. HIM processes, copies for DON review, then scans and routes for electronic signature.
  • Nursing Home Transfers: Scan transfer forms into the EMR.

Medicaid / SBS Processing

• Fax required SRS (MS-2126) documentation at admission and discharge.
• Identify applicable insurance types (KanCare, Sunflower, Healthy Blue).

Death Log Maintenance

• Record all hospital patient deaths (including ER, excluding long-term care units) in the death log.

Qualifications

• High school diploma or equivalent required; HIM training preferred.
• Knowledge of medical terminology and healthcare documentation practices.
• Experience with EHR systems (Cerner preferred).
• Strong attention to detail and organizational skills.
• Ability to maintain confidentiality and comply with HIPAA regulations.
• Proficiency in Microsoft Office, especially Excel.

Work Environment

• Hospital setting with frequent interaction with clinical and administrative staff.
• Regular use of computers, scanners, and office equipment.
• May require lifting boxes up to 25 pounds.