Job Description

Job Summary

The Medical Records Coordinator plays a vital role in managing and maintaining residents' medical records within a healthcare facility. This position requires a detail-oriented individual with a strong understanding of medical terminology and experience with electronic health record (EHR) systems. The coordinator will ensure that all patient in

Summary:

Maintain residents' medical records in accordance with facility policies and with state and federal regulations.

Environment:

Work will be performed primarily indoors at a long-term healthcare facility, throughout all areas, including in resident rooms, and on carpeted and/or tiled floors. Work will also be performed routinely around other co-workers, healthcare staff, residents, and guests.

Essential Duties & Responsibilities:

Meet physical and sensory requirements stated below, and be able to work in the described environment. Identify and participate in process improvement initiatives that improve the customer experience, enhance work flow, and/or improve the work environment. Organize and maintain facility medical records system in compliance with corporate, state and federal regulations. Code and quantify records from admission to discharge. Maintain a documented, organized system, which is readily accessible by other authorized professionals. Ensure that all reports are completed within established time frames. Maintain the resident census on a daily basis. Maintain a current list of each physician's residents and send to the physician quarterly. Pull charts for physicians' rounds each week and ensure that documentation is present. Monitor Restraint and Bowel & Bladder Programs to insure documentation is present. Audit MAR and Treatment Sheets weekly. Audit Narcotic count sheets weekly. Perform chart audits as follows: Admission audit - twenty four (24) hours after admission Weekly audit of physician visits, progress notes, and nursing notes to ensure that all signatures and dates are present. Monthly audit of progress notes for all departments, monthly summaries, history and physical, etc., to ensure that all forms are present and completed. Discharge audit - chart is to be complete within seventy two (72) hours including discharge summary and arrangement in chronological order in each section of the chart so that material can be retrieved in an efficient manner. File lab and x-ray reports on charts daily. Review physician orders (including telephone orders) and monitor to be sure that lab, x-ray, diagnostic tests, consultations, etc., have been scheduled and followed through. Maintain log/roster to identify when care plan meetings are due. Ensure that MDS documentation is placed in resident's medical record and that documentation is complete. Ensure that MDS quarterly review sheets are completed with each care planning conference. Schedule care plan meetings. Notify family and staff thirty (30) days in advance of care plan meeting, fifteen (15) days in advance and one (1) week in advance. Obtain the following information for admission of a new resident: History & Physical, Admit orders, Physician's Statement (Part of PAE), TB skin test and/or chest x-ray. Prepare ID bracelet and laminated name for the door for each new resident. Maintain a list of residents hospitalized and dates of hospitalizations. Prepare blank charts for admissions. File discharged charts, QA reports, minutes of meetings, and consultant reports (all departments). Thin charts according to facility policies and arrange overflow in discharge chart order. Maintain adequate stock of medical forms and documentation supplies. Coordinate discharge and death records. Collect medical records upon discharge or death, assemble them in proper order, and check for completeness. Incomplete charts are returned for proper correction or completion to nursing service or attending physician. Maintain minutes of meetings/files, as necessary. Return incomplete records/charts to nursing service for correction. Answer telephone inquiries concerning medical records functions.; prepare written correspondence, as necessary. Other special projects and duties, as assigned.

Job Requirements:

High school diploma or GED required or equivalent related work experience AND Registered Health Information Technician (RHIT) Certification AND/OR Certified Nursing Assistant, Registered Nurse or Licensed Practical/Vocational Nurse with current state license. One (1) to three (3) years related experience; supervisory experience preferred, as necessary. Practical knowledge of medical terminology and record keeping. Effective verbal and written English communication skills. Demonstrated basic to intermediate skills in Microsoft Word, Excel, Power Point and Outlook, Internet and Intranet navigation. Highest level of professionalism with the ability to maintain confidentiality. Ability to communicate at all levels of organization and work well within a team environment in support of company objectives. Customer service oriented with the ability to work well under pressure. Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity. Strong analytical and problem solving skills. Ability to work with minimal supervision, take initiative and make independent decisions. Ability to deal with new tasks without the benefit of written procedures. Approachable, flexible and adaptable to change. Function independently, and have flexibility, personal integrity, and the ability to work effectively with employees and vendors.
Job Type: Full-time

Expected hours: 32 per week

Work Location: In person