Position Description Pay $16-20 hourly pending experience 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. Principal Responsibilities Assist in planning, developing, organizing, implementing, evaluating, and directing the medical records and health information system in accordance with established policies and procedures and professional standards of practice. Assist in establishing procedures to be followed in the collection, coding, indexing, and the filing/retrieving of medical records and health information Advise the administrator on federal and state laws concerning medical records and health information issues Review discharge and death records, as well as records on the nursing units. Review departmental 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 the appropriate department or personnel for correction. Assist in developing procedures to ensure records are properly assembled, coded, signed, indexed, etc., before filing. Ensure established policies and procedures governing medical records and health information is followed by all personnel. Assist in developing procedures to ensure records are properly assembled, coded, signed, indexed, etc., before filing. Ensure established policies and procedures governing medical records and health information is followed by all personnel. Assist in establishing procedures to ensure that charts/records are not taken from the records room except as authorized. Periodically check such records to assure this policy is being followed. Assist the medical records/health information clerk in maintaining a record of authorized information taken from charts/records (i.e., type information, name of recipient, date, department, etc.). Abstract information from records as authorized/required for insurance companies, Medicare, etc. Assist in indexing medical records as necessary. Ensure that registries are properly maintained for admission and discharge of residents. Prepare medical records for court trials as required. Assume the authority, responsibility, and accountability of the medical records consultant. Assist in the development and implementation of our written medical records policies and procedures. Devote such time, energy, and skill necessary to maintain accurate medical records. Provide written, dated, and signed reports to the administrator of each consultation visit. Provide the facility with a signed and dated business associate agreement in accordance with current HIPAA rules, regulations, and guidelines Communicate with physicians and other personnel as necessary to ensure proper interpretation of dictated information. Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator. Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator. Qualifications Medical Coding One year's work in Medical Record Degree in Health Information Tech is preferred, but not mandatory