QUALIFICATIONS:

1. High School Graduate, 3 years experience in a healthcare setting
2. Accreditation by the American Medical Record Association preferred.

POSITION SUMMARY:

Coordinates and performs a variety of tasks in maintaining and updating Residents Medical records and compiling data and records as required by the DOH and Federal regulations.

PART 1: JOB RESPONSIBILITIES AND STANDARDS

1. Assembles and supervises medical record in its proper order.

2. Does QA of records to assure completeness and accuracy and internal consistency following admission and discharge; reports findings to Coordinator of Medical Records.

3. Notify MD that he/she has a medical record to complete according to policies of the facility and or accrediting agencies.

4. Maintain the necessary indexes (deceased, discharge) according to the needs of the facility and following the established classification systems. 

5. Reports concerns and seeks out information from Medical Records consultant if needed.

6. Notify social worker and other ancillary supervisors to complete their portion of the medical record according to policies of the facility and/or accrediting agencies.

7. Maintains Records of outside consults and tracts requests.

8. Maintain the uniformity of Medical terminology among department and tracts through QA any discrepancies.

9. Provides data and reports to Quality Assurance Committee as requested.

10. Collect and correlate statistical data from the Unit Clerks and other departments by manual means.

11. Maintains all Medical Record storage areas in good order with full HIPAA compliance.

12. Supervises filing system for current and discharge medical records that meet the needs of the facility DOH and Federal Regulations.

13. Maintains chart out and follow-up control system of records.

14. Under leadership of the Chief Corporate Compliance Officer, maintains and controls the release of PHI to authorized persons only as dictated under HIPAA Guidelines.

15. Assists medical staff by providing date from the medical records for utilization review and any medical audits.

16. Provides information, when requested, to those parties who are engaged in research or study projects involving patient care and utilization of services.

17. Monitor physician’s compliance in completing medical record upon discharge. 

18. Assists and advises Administration in maintaining a medical record system which complies with licensing and accreditation agencies.

19. Assists in the development of policies and procedures for the retention and safe-keeping of medical records with full HIPAA Compliance.

20. Maintains files on all accident and/or incident reports for residents.

21. Checks transfer summary from hospital for completeness. Contact transferring facility for additional information if necessary.

22. Completes all necessary paperwork required by the admission policies and procedures for the admission of any resident by the facility.

23. Works with MDs during monthly rounds if requested.

PART II: FACILITY-WIDE RESPONSIBILITIES & STANDARDS

1. Must function independently, have flexibility, personal integrity & the ability to work effectively with residents, family members, personnel & support agencies.

2. Demonstrates courtesy to residents, co-workers and visitors.

3. Demonstrates knowledge of HIPAA and Resident Confidentiality.

4. Demonstrates ability to work with others.

5. Demonstrates flexibility in assignment to meet resident/facility’s needs.

6. Demonstrates knowledge of the Organization’s Performance Improvement process.

7. Arrives for work on time as scheduled on a consistent basis. Uses time effectively.

8. Adheres to departmental dress codes.

9. Knows and understands policy and procedure on abuse.

10. Supervises personnel and acts in professional manner at all times.

11. Knows responsibility & procedure in emergencies.

12. Assume accountability for all data contained in the Employee Handbook.

13. Attends mandatory scheduled in-services/meetings.

14. Keeps current on new and revised DOH and Federal Regulations.

PART III: PHYSICAL REQUIREMENTS OF THE JOB ACTIVITY

1. Demonstrate ability to handle stressful situations.

2. Must be able to write & speak the English language in an understandable manner.

3. Must function independently, have flexibility, personal integrity & ability to work effectively with resident, family members, personnel & support agencies.

4. Ability to relate and work with the physically and emotionally challenged residents.

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