Job Summary
Pacific Coast Home Health Services LLC is seeking a detail-oriented and organized Medical Records Clerk to maintain accurate, complete, and confidential patient medical records. The Medical Records Clerk is responsible for ensuring that patient documentation complies with federal, state, and agency regulations while supporting clinical and administrative staff in delivering quality home health services.
Essential Duties and Responsibilities
• Maintain, organize, and manage patient medical records in both electronic and paper formats.
• Review patient charts for completeness, accuracy, and required documentation.
• Scan, upload, and index medical documents into the electronic medical record (EMR) system.
• Ensure compliance with HIPAA, Medicare, Medicaid, and applicable state regulations regarding medical records.
• Process requests for medical records in accordance with agency policies and privacy laws.
• Track missing documentation and communicate with clinicians to obtain required records promptly.
• File physician orders, care plans, visit notes, laboratory reports, and other clinical documentation.
• Prepare records for audits, surveys, accreditation reviews, and billing purposes.
• Maintain document retention and record destruction schedules according to regulatory requirements.
• Assist with patient admissions by creating and maintaining new patient files.
• Coordinate with clinical staff to ensure timely completion of documentation.
• Maintain strict confidentiality of patient information at all times.
• Perform general clerical duties, including filing, copying, faxing, scanning, and answering telephone inquiries related to medical records.
• Participate in quality improvement activities and departmental meetings as assigned.
• Perform other duties as assigned by management.
Qualifications
Education
• High school diploma or equivalent required.
• Associate degree in Health Information Management, Medical Office Administration, or a related field preferred.
Experience
• Minimum of one (1) year of medical records, health information management, or healthcare administrative experience preferred.
• Home health, hospice, or healthcare agency experience is preferred.
• Experience using Electronic Medical Record (EMR) systems is preferred.
Knowledge, Skills, and Abilities
• Knowledge of HIPAA regulations and medical record confidentiality.
• Understanding of Medicare and home health documentation requirements is preferred.
• Strong organizational and time-management skills.
• Excellent attention to detail and accuracy.
• Proficiency in Microsoft Office applications and electronic health record systems.
• Strong written and verbal communication skills.
• Ability to manage multiple priorities and meet deadlines.
• Ability to work independently and as part of a multidisciplinary team.
• Professional demeanor with excellent customer service skills.