Medical Records Specialist

Description

 SUMMARY

To maintain all medical records in accordance with Federal, State, local regulations, and company policy and procedures. ESSENTIAL DUTIES AND RESPONSIBILITIES

include the following. Other duties may be assigned.

• Provide daily reports during clinical stand up to include past due forms, clinical alerts, orders, admissions, discharges, etc.

• Compile and set up residents’ medical records and enter data into software system.

• Collect information from nursing staff, physicians, and other sources and update data in software and hard copy needed.

• Monitor and audit records for completeness and accuracy in accordance with company policies and state regulations.

• Provide resident information to the approved personnel as needed.

• Process transfer or discharge record and discharge auditing.

• Maintain appropriate records on former residents, storage per company policy.

• Assist in coordinating Nursing Department activities to include administrative support and audits and education.

• Run errands that may include travel to hospitals and doctor offices for documentation needing signatures.

• Daily auditing of skilled care documentation as well as changes in condition for all records.

• QI and IC functions as directed.

• Routine daily, weekly, monthly and quarterly medical records audits.

• PDPM Committee meeting member responsibilities.

• Resolve/clarify codes and diagnoses with conflicting, missing or unclear information and consult with doctors or others to get information.

• Prepare statistical reports or narrative reports for physician, facility, company, or state agency (vital records, death report, infection reporting).

• Prepare hard copy of records for use during power failures and emergency situations as per policy.

• Compile census, demographic or medical data as requested by facility, company, or state/federal agency.

• Oversee appropriate use and documentation in software and provide audits/education as needed or directed.

• Update CNA task daily with changes as they occur based on orders and information discussed during the clinical meeting.

• Trigger forms based on MDS schedule and forms table. • HIPAA Privacy Officer responsible for the facility’s HIPAA compliance, in conjunction with the Administrator and HIM, including but not limited to all regulations, laws, policies and procedures, forms and logs.

• Other duties as assigned.

Requirements

Requirements

EDUCATION and/or EXPERIENCE• Licensed Practical Nurse or Registered Nurse• Preferred 2 years of experience in Long Term Care. KNOWLEDGE, SKILLS AND ABILITIES• Excellent written and verbal communication skills.• Ability to multi-task while being detail oriented.• Customer Service focus.• Intermediate computer skills.• Experience with MS Office Word, Excel, and PowerPoint preferred.• Preferred experience with Point Click Care.