Job Description

Team Member Benefits & Programs:

Shift differential and mod comp bonuses New hire welcome gift package $1,000+ staff referral reward program $150 awarded during your initial 90-days, $100+ on your annual work anniversary & $100 on your birthday Tuition Reimbursement Program, Paid Career Advancement Program & Mentorship Program Paid time off Health, dental, vision, disability & life insurances available 401k program Employee appreciation events And so much more!

RESPONSIBILITIES/ACCOUNTABILITIES:

1. Maintains the Diagnosis List/Sheet in the electronic system. Performs ICD


coding as trained and in consultation with Nursing/Clinical Reimbursement


Coordinator (CRC) or Clinical Care Manager (CCM).



2. Creates medical record for all new admissions, as directed by Director of


Nursing (DN) or designee.



3. Maintains accurate order of open records, paper and electronic by:

Filing forms, Thinning records, Notifying physicians of need to sign admission/monthly orders and Medicare Certifications in a timely manner, Monitoring quality control documents, as directed by DN or designee.


4. Performs routine audits of medical records upon admission, throughout the stay,


and discharge to monitor compliance with policies regarding documentation,


physician visits, timeliness, etc.



5. Maintains forms/office supplies inventory, as directed by DN or designee.



6. For centers with Medication Administration Records (MARs) and Treatment


Administration Records (TARs) supplied by pharmacy, communities with the


pharmacy in reference to additions/deletions of patient MARs/TARs and other


pharmacy-supplied forms.



7. Processes medical record requests:

Confirms all health information requested with DN or Administrator to comply with HIPAA and GHC policies and procedures, Coordinates with Corporate Risk Management Department to ensure clearance for record release to outside sources other than payers and those identified by patient during admission process, Upon Center/Risk Management clearance and direction, retrieves, copies, and forwards information from the medical record.


8. Maintains closed records in accordance with Company policies and procedures.

Obtains all appropriate departmental and physician signatures on discharge

charts within 30 days of patient discharge.



9. Responds to telephone inquiries concerning medical records and may respond to correspondence, as directed by center management.



10. Performs other duties as requested.

COMPLIANCE:

1. Complies with applicable legal requirements, standards, policies and procedures including but not limited to those within the Compliance and Ethics Program, Standard/Code of Conduct, Federal False Claims Act and HIPAA.



2. Participates in required orientation and training programs.



3. Promptly reports concerns and suspected incidences of non-compliance to


supervisor, Compliance Liaison or to the Compliance Officer via the Integrity


Hotline.



4. Cooperates with monitoring and audit functions and investigations.



5. Participates, as requested, in quality assurance and process improvement


activities.

SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS:

1. High school graduate or equivalent.


2. Experience with ICD coding preferred


3. This position requires that the employee is able to read, write, speak and understand the spoken English language to ensure the safety and wellbeing of


our patients and visitors at the work site when responding to their medical and


physical needs.


4. Able to communicate effectively with patients, family members, staff and


external requestors of medical records and/or information.


5. Sufficient computer skills to perform duties


6. Verification of the TST (tuberculin skin test) and results as required by state law


and in accordance with Company policy, if required, the TST will be administered at the work site.


7. Successful completion of the Company training program upon hire to position.