Description

SUMMARY: The primary purpose of this position is to assure that medical records are maintained in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained. 

SUPERVISOR: Health Center Administrator

DUTIES AND RESPONSIBILITIES:

• Plan, develop, organize, implement, evaluate, and direct the medical records section in accordance with established policies and procedures. Includes department policies and procedures, position descriptions, etc. 
• Review discharge and death records, as well as records on the floor.
• Maintain 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. 
• Prepare medical records for court trials as required. 
• Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed. Attend such meetings as may be necessary or appropriate. 
• Assist in the development of and participate in in service, orientation classes, and on the job training programs. 
• Ensure that work areas are clean and that records are properly stored. 
• Scan documents daily to comply with medical records requests.
• Maintain proper documentation of five-day flu.

Requirements

MINIMUM QUALIFICATIONS: 

• Must possess the ability to make independent decisions, follow instructions, and accept constructive criticism.
• Must be able to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
• Must be able to work with ill, disabled, elderly, emotionally upset, and potentially hostile people within the facility. 
• Must be able to speak, write and understand English in a manner that is sufficient for effective communication with supervisors, employees, residents, and families

LICENSES OR CERTIFICATIONS REQUIRED:

• None 

COMPLIANCE: 

This position requires compliance with API's written standards, including its Compliance Program and Standards of Conduct and policies and procedures. Such compliance will be an element considered as part of the regular performance evaluation.

Failure to comply with API's Written Standards, which may include the failure to report any conduct or event that potentially violates legal or compliance requirements or API's Written Standards or, for managers and supervisors, fails to detect non-compliant conduct where reasonable efforts would have resulted in detection, will be met by the enforcement of disciplinary action, up to and including possible termination, in accordance with API's Compliance Program Policy and Procedure: Addressing Instances of Non-Compliance through Appropriate Disciplinary Actions.

PHYSICAL DEMANDS: 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit, and use hands to finger handle or feel; to talk; or hear. The employee is frequently required to reach with hands and arms. The employee must occasionally stand, walk, climb or balance, stoop, kneel, crouch or crawl. The employee must be able to frequently lift up to 25 pounds. The employee may occasionally be required to lift 25 to 50 pounds; however, this is not essential; duties may be shifted to accommodate lifting restrictions.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to use close vision (clear vision at 20 inches or less). The employee will occasionally be working near moving mechanical parts, be exposed to outdoor weather conditions and exposed to a risk of electrical shock while running the copier, printer, other standard equipment and answering the telephone. The noise level in the work environment is low to moderate. Stress level can be high at times.

Note: This job description is not intended to be an exhaustive list of all duties, responsibilities or qualifications associated with the job.