The primary purpose of this position is to oversee the entire Medical Records Department to ensure the accuracy of New York State Department of Health submissions (PRIs and MDSs). This will include collecting, inspecting the completion of and signatures of medical records, coding, indexing, filing, retrieving medical records, transcribing physician’s notes and evaluations, therapist notes and other disciplines as deemed necessary. All medical record information is to be treated as highly confidential.

EDUCATION, EXPERIENCE AND QUALIFICATIONS: Must possess New York State Certification as an Accredited Records Technician (A.R.T.) or the equivalent in experience in the medical records field/department. Health care, supervisory, and computer experience highly preferred.

DUTIES AND RESPONSIBILITIES:

• Coordinates, organizes, and plans the Medical Records Department.
• Establishes and implements policies and procedures of the Medical Records Department.
• Establish procedures to be followed in the collection of, inspection for completion and signatures of, coding, indexing, filing, and retrieving of medical records.
• Check records, according to established criteria, to assure completeness, accuracy, and internal consistency while the patient is in the facility and following discharge.
• Obtain complete and accurate records within the time specified by the Vice President – Health care, and by the state and federal codes.
• Coordinate medical record information needed for transfers, discharges, and for admissions. Maintain the flow of the reports to the files (records).
• Responsible for assuring charts are thinned according to facility, state, and federal policy.
• Collect and correlate statistical data from the records and other departments (Nursing) by manual means or by the completion of source document sheets for electronic data processing and transmittal.
• Maintain current PRI analysis. Monitor CMI and PRI submissions. Analyze data as it pertains to reimbursement, make recommendations to the Quality Assurance Director and/or the Vice President – Health Care.
• Work closely with the Nursing Staff and monitor chart documentation to assure appropriate nursing documentation exists for maximization of PRI reimbursement.
• Assure PRI submissions are entered and submitted in a timely manner to the New York State Department of Health in accordance with rules and regulations.
• Assure MDS submissions are entered and submitted in a timely manner to the New York State Department of Health in accordance with rules and regulations. Oversee the Receptionists function of MDS submissions and work with the Receptionist Supervisor to assure timely, accurate submissions.
• Direct and assist in coordinating the computerization of the Medical Records Department.
• Maintain the necessary indexes (i.e. patient, disease, procedures, etc.) according to the needs of the facility; and follow the established nomenclatures.
• Code all diagnoses from admission and throughout patients stay including final diagnosis in disease index according to established nomenclatures.
• Maintain the filing system for records that meets the needs of the facility.
• Maintain the Patient Master Card File.
• Maintain the necessary charge-out and follow-up controls of records.
• Maintain the established numbering system for record identification.
• Responsible for the completion and arrangement of medical records upon discharge or death and for obtaining signatures and discharge summaries, etc.
• Maintain and control the release of information to authorized persons.
• Assist health professionals in medical audits and reports when required.
• Attend Quality Assurance meetings of the facility as needed.
• Participate in conducting Quality Assurance studies and participate in quality circles for continuous quality improvement.
• Perform any other pertinent duties as assigned by my supervisor.
• I understand that emergency conditions may require me to temporarily work shifts other than the one for which I have applied and been assigned, and agree to such scheduling change or overtime when necessary to ensure proper operation of the Homes as directed by my supervisor.

PERSONAL REQUIREMENTS AND WORKER TRAITS:

• Must possess a sense of responsibility and integrity.
• Must possess a spirit of cooperation and exhibit a pleasant personality.
• Must possess a warm feeling of concern and love for the aging and handicapped.
• Must be capable of mature judgment.
• Must possess the ability to communicate effectively with staff and residents.
• Appropriate attire, as mandated by department dress code, is required at all times.

PHYISCAL DEMANDS AND WORKING CONDITIONS:

• Works in well-lighted, ventilated, controlled environment.
• Works very closely with others in the department and within the facility.

VOCATIONAL DEVELOPMENT: Attends in-service programs and staff development programs as provided by the facility to maintain compliance with the Department of Health and other regulatory agencies, as well as Nursing Home policies and procedures.

JOB HAZARDS: Minors are prohibited from performing certain duties involving the use of power driven equipment and the mixing and usage of chemicals as outlined by labor law regulations.

Lifting requirements/restrictions.

• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.

PERSONAL PROTECTIVE

EQUIPMENT: N/A

CONTACTS: Staff and residents

JOB RELATIONSHIPS: Supervised by: Asst. Admin.

Workers Supervised: N/A