Medical Records Coordinator

POSITION SUMMARY

The purpose of this position is to implement facility policies and procedures to organize and maintain the medical record (health information) system in compliance with federal, state and local requirements. Also, to maintain a medical record system to meet the needs of the facility residents.

ESSENTIAL FUNCTIONS

1. Work cooperatively with facility staff. 2. Assure that all medical record information is protected and kept confidential. 3. File medical records promptly and accurately. 4. Protect all medical record information from loss, defacing or destruction before retention period ends. 5. Handle overflow from in-house records and file in discharge record order. 6. Assemble admission packets. 7. Process admission and discharge records timely and accurately. 8. Verify diagnoses with Director of Nursing Service and record on admission record. 9. Audit medical records, as assigned. 10. Receive and file all diagnostic reports promptly and accurately. 11. Audit transfer/discharge information for accuracy and completeness. 12. Assist with data entry, printing and processing of computer forms, as assigned. 13. Retrieve medical records promptly upon request by authorized individuals and agencies. 14. Identify late and incomplete documentation and report to individuals responsible for completion. 15. Identify inaccurate documentation and report to individuals responsible for accuracy and documentation. 16. Implement the system developed by the administration for advising all disciplines of documentation to be completed or corrected. 17. Mail forms to physicians, for completion, to the extent permitted by regulations. 18. Maintain an accurate resident census report and distribute to designated individuals. 19. Complete all information in master resident index file. 20. Notify Administrator of all requests for information from medical records. 21. Answer correspondence regarding release of information from medical records. 22. Prepare records in answer to subpoenas. 23. Record, type and file minutes for all committee meetings as assigned. 24. Ensure Medicare residents have timely certification/re-certification forms signed by the attending physician. 25. Enter data into the computer timely, accurately and completely. 26. Print forms and reports from the computer program as required. 27. Assist with quality assessment and assurance studies. 28. In the absence of a ward clerk, the medical record clerk performs the duties of the ward clerk. 29. Assume duties related to record review and data collection to verify Quality Indicators as assigned. 30. Observe all facility safety policies and procedures. 31. Perform other related duties as directed by his/her supervisor. 32. Observe all infection control procedures. 33. Accept assigned duties in a cooperative manner. 34. Assume accountability for all data contained in the employees' handbook. 35. Assume Quality Assurance duties as assigned. 36. Come to work in neat, clean attire and consistently present an appropriate professional appearance. 37. Come to work as scheduled and consistently demonstrate dependability and punctuality. 38. Complies with laws and regulations applicable to position and acts in accordance with facility Compliance Program. 39. Treats all residents, visitors, and staff with courtesy. 40. Attends and participates in in-service training, performance improvement (PI) committees and other meetings as scheduled and directed. 41. HIPAA

• Follows and adheres to facility policies and procedures implementing HIPAA requirements for the privacy and security of protected health information.
• Uses and/or discloses only minimum amount of protected health information necessary to complete assigned tasks.
• Reports all suspected violation of facility HIPAA policies or procedures to the Administrator. 42. Resident Rights
• Knows Resident Rights. Helps the residents exercise and/or protect their rights.
• Reports resident complaints to management.

OTHER DUTIES

1. Assist nursing staff, as assigned. 2. Assist administrative staff, as assigned. 3. Assist DON with infection control/ATB stewardship program, as assigned. 4. Performs other duties as assigned and consistent with level of preparation and experience. 5. Participates in facility programs as appropriate. 6. Participates in marketing events as needed. 7. Works overtime, holiday, and weekend hours as scheduled.

MINIMUM QUALIFICATIONS

Education:

High school diploma or equivalent.

Experience:

One year of current experience in a comparable job classification required. Long term care experience preferred. Medical terminology required.

Skills, Knowledge and Abilities:

General computer literacy and good knowledge of Microsoft Outlook, Excel and Word. Working knowledge of office machines (copier, fax, phone systems, etc.) Good organizational and communication skills. Ability to relate positively, effectively and appropriately with residents, families, community members, volunteers and other facility staff. Possess special interest in and a positive attitude about working with long-term care residents and the elderly. Ability to read, write, speak and understand English. Demonstrates basic computer knowledge and ability with an aptitude to learn facility applications.

ENVIRONMENTAL AND PHYSICAL REQUIREMENTS

The responsibilities of this position involve significant physical activities including standing, lifting (up to 60 pounds unassisted), bending, stooping, pushing, pulling and twisting. All employees of nursing homes may be required to provide lifting and transfer assistance to residents.

Job Type:

Full-time Pay:

$12.00 - $15.00 per hour

Benefits:

Dental insurance Flexible schedule Health insurance Paid time off Vision insurance

Work Location:

In person