Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that 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. All duties and responsibilities shall be performed as set forth in our established policies and procedures Adheres to and assures compliance with Code of Conduct, facility policies and procedures and all applicable rules, regulations and standards as promulgated by Federal, State, and accrediting agencies or regulating bodies. This includes, but is not limited to, Department of Health, Centers of Medicare and Medicaid Services, and other applicable regulatory agencies. Assures that all staff complete required compliance training and processes. Plan, develop, organize, implement, evaluate, and direct the medical records section in accordance with established policies and procedures. (Includes department policies and procedures, job descriptions, etc.) Establish procedures to be followed in the collection, coding and indexing, and the filing/retrieving of medical records. Assist the medical records director as required. Review discharge and death records, as well as records on the nursing units. Review department policies and procedures, at least annually, and participate in making recommended changes. Collect, assemble, check, and file resident charts and personnel records as may be necessary. Ensure that incomplete records/charts are returned to nursing service for correction. Develop procedures to ensure records are properly assembled, coded, signed, indexed, etc., before filing. Ensure established policies and procedures for the medical records section are followed by all personnel. Establish procedures to ensure that charts/records are not taken from the section except as authorized. Periodically check such records to assure this policy is being followed. Abstract information from records as authorized/required for insurance companies, Medicare, etc. Ensure that registries are properly maintained for admission and discharge of residents. Prepare medical records for court trials as required. Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed. Attend such meetings as may be necessary or appropriate. Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility to assure that medical records can be properly maintained and problem areas can be identified and corrected. Maintains confidentiality by securely collecting and emptying departmental Shred bins on a regular schedule. Education and Experience High school diploma is preferred. Must be a graduate of an approved course for medical record technicians. Other Specific Requirements Must be able to write, read, speak, and comprehend the English language. Must possess the ability to follow instructions and to accept constructive criticism. Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public. Must maintain the care and use of supplies, tools, equipment, etc., and maintain the appearance of maintenance work areas. Must be willing to work harmoniously with other personnel as well as be willing to handle residents based on whatever maturity level they are currently functioning. Must have the ability to minimize waste of supplies, misuse of equipment, etc. Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing dietary practices. Must be able to follow written and oral instructions. Must be able to relate information concerning a resident's condition. Must not pose a direct threat to the health or safety of other individuals in the workplace.