What are the responsibilities and job description for the Medical Records Nurse position at MEDICALODGES INC.?
Medical Records Nurse
We Own It!. Medicalodges is a 100% employee-owned organization with over 30 skilled nursing and assisted living facilities committed to providing the highest quality of care to our residents. If you have a passion for providing seniors with outstanding care we want to talk with you today!
Job Responsibilities:
- Keep all current medical files up-dated and filed in an organized manner.
- Assemble charts for use upon admission of a new resident. Disassemble resident charts upon dismissal and following up to ensure the record is complete and in proper order.
- Updating Nursing Chart Audit monthly using audit forms as well as computer audit.
- Performing daily spot check of MAR’s and following up timely, accurate documentation on accidents/incidents, condition changes, etc.
- Maintaining and organizing the central supply room and the inventory control list for all items received or removed from central supply.
- Monitoring Medicare certifications and recertifications for completion and timeliness of physician’s signature.
- Maintaining accurate listing of resident diagnoses and making corrections when necessary
- Antibiotic Stewardship Duties: Implement or oversee the implementation of Core Elements of Antibiotic Stewardship. Proper documention of order. Review clinical approriateness of order. 48 hour follow up.
- Create and present monthly anitbiotic use reports to present during QAPI meetings with the Medical Director and Consultant Pharmacists.
- Other duties as assigned
Job Requirements:
- Current LPN or RN license for the state in which the facility is located.
- Knowledge of basic medical terminology
- Knowledge of healthcare regulations and laws including state and federal regulations.
- Ability to perform basic clerical/office skills and file management skills
- Excellent attention to detail
- Strong written and verbal communication skills
Company Benefits:
- Paid Time Off
- Employee Stock Ownership Program
- Insurance benefits & 401k
- Educational Assistance
#INDNURSE