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Job Summary

The overall purpose of the Medical Records Technician position is to establish and maintain organized medical records and files, according to acceptable policies and procedures that include OBRA guidelines and Texas, NM, LA state standards. At times, this position may provide clinical and administrative support to the nursing department.

Qualifications:

• Registered Health Information Technician or high school graduate (or equivalent)
• Accurate typing skills of 40 wpm or more are needed
• Minimum of one-year experience in medical records within a long-term care setting is preferred
• Computer literacy is mandatory
• Ability to read, speak, and write the English language

Essential Functions:

• Maintains established medical record files; scans in documentation in the EMR accordance with company policies and procedures as well as federal and state-specific regulations.
• Scans (Files) Patient information in individual charts accurately.
• Establishes and maintains inventory of forms, and supplies for Nurses station. Prepares spend-down sheets and submits to Executive Director.
• Prepares any correspondence for medical records.
• May enter physicians orders into the clinical software system when applicable.
• May enter weights into the clinical software system.
• Keeps a soft file of weights in medical record office.
• Submits interim orders and physicians order sheets monthly to physicians for signature and ensures timely e-signature.
• Participates in Monthly Quality Assurance Meeting.
• Audits medical records per company policy and procedure and notifies all physicians of compliance issues with H&Ps and Progress Notes.
• Submits daily, weekly, and monthly audits of charts to Unit Managers, Director of nurses & appropriate department heads for review, correction or closing of forms.

• Copies all requested documents and keeps requests in a folder clearly visible in medical records. Records request may be discarded 1 year from request being filled.
• Maintains a log of all medical records requests for quick reference.
• Ensures all discharge records are closed as specified in Medical Records Manual.
• Ensures the completion of discharge summary (IDT) and all documents under assessments.
• Works with legal counsel to prepare records for release of information.
• Reviews Cantex Continuing Health Care, LLCs Clinical Policies and Procedures for Abuse prevention and knows the employees responsibility to enforce it.
• Attends weekly in-services, understands, and complies with Patient Care Management Systems.
• Perform other duties and tasks as assigned.

Diversity, Equity, and Inclusion are at the heart of Cantex. We are committed to a culture that respects our differences and values the contributions of all people.

We are an Equal opportunity employer; We offer an excellent benefit plan to include 401K with match, CEU reimbursement, vacation, sick, holidays, medical, dental, and supplemental insurance Plans as well as a Highly competitive compensation package.