GENERAL OVERVIEW OF KEY ROLES & RESPONSIBILITIES:

The Quality Management/Medical Records Clerk supports the Quality Management Department by organizing, maintaining, tracking, and reviewing client medical records. This position helps ensure that documentation is complete, accurate, timely, and compliant with all applicable federal, state, managed care, accreditation, and organizational requirements.

This role collaborates with clinical, administrative, and quality staff to support chart audits, record retention, quality improvement activities, regulatory compliance, and medical record accuracy. The role also assists with monitoring documentation, preparing for audits and reviews, tracking corrective actions, and supporting the organization's efforts to maintain high-quality services across all agency programs.

ESSENTIAL & CORE FUNCTIONS:

1.     Conduct routine medical record audits using established audit tools and quality indicators.

2.     Review records for required assessments, treatment plans, progress notes, consents, authorizations, and other required documentation.

3.     Prepare audit reports and communicate findings to Quality Management leadership.

4.     Maintain electronic and paper medical records in accordance with organizational policies and regulatory requirements.

5.     Ensure medical records are accurately filed, indexed, scanned, and stored.

6.     Monitor records for completeness and identify missing documentation.

7.     Process requests for medical records in accordance with HIPAA and confidentiality requirements.

8.     Maintain record retention and destruction schedules.

9.     Support preparation for internal and external audits, licensing reviews, and accreditation surveys.

10.  Assist with gathering and organizing documentation requested during audits and investigations.

11.  Assist with policy, procedure, and training documentation management.

12.  Schedule meetings and maintain quality management files as assigned.

13.  Provide clerical support to the Quality Management Department.

ADDITIONAL RESPONSIBILITIES:

1.     Perform other duties and special projects as assigned.

PREREQUISITES & QUALIFICATIONS FOR THE POSITION:

1.     Associate degree in Health Information Management, Healthcare Administration, Business Administration, or related field preferred

2.     High School Diploma or GED required.

ORGANIZATIONAL ACCOUNTABILITY & RELATIONSHIPS:

1.     Quality Management/Medical Records Clerk reports to the Director Quality Management and Training 

COMPETENCIES & PERSONAL CHARACTERISTICS

1.     Knowledge of medical records management principles and practices.

2.     Understanding of HIPAA, confidentiality requirements, and record retention standards.

3.     Knowledge of Medicaid, managed care, and regulatory documentation standards preferred.

4.     Strong attention to detail and organizational skills.

5.     Ability to review documentation for accuracy and completeness.

6.     Proficient in Microsoft Office Suite, including Word, Excel, Outlook, and electronic health record systems.

7.     Strong written and verbal communication skills.

8.     Ability to maintain confidentiality and exercise professional judgment.

PHYSICAL DEMANDS:

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 accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. The employee must occasionally lift and/or move up to 25 pounds.

Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

WORK ENVIRONMENT:

Work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is exposed to weather conditions prevalent at the time.  The noise level in the work environment is usually moderate.

GENERAL SIGN OFF:

The employee is expected to adhere to all agency policies and to act as a role model in adherence to agency policies.

I have read and understand this explanation and job description.

Signature: _____________________________________________ Date: ______________

Human Resources/Management Signature: ____________________________________ Date: ____________