Job Description
POSITION SUMMARY
The purpose of your job position is to maintain resident Medical Records and health information in accordance with current federal, state and local guidelines that govern the facility and as directed by the Administrator.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Retrieving resident’s records when requested
- Managing accurate and timely requests of Medical Records
- Organizing and directing the Medical Records department in accordance with facility policies
- Assembling and reviewing resident’s Medical Records as needed.
- Ensuring the filing of all medical reports, doctors and nurses notes, x-ray, lab, etc.
- Enforcing procedures to ensure all resident Medical Records are properly filed, coded, and signed
- Maintaining a record of authorized information released from charts/records
- Keeping active and inactive Medical Records as warranted by company policy
- Protecting each residents file and data with confidentially per HIPAA standards
- Abiding with all facility policies and procedures including not disclosing user ID codes and passwords
- Attending meetings and serving on committees as needed
Every effort has been made to identify the essential functions of this position. However, it in no way states or implies these are the only duties you will be required to perform as directed by management. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.
REQUIREMENTS
Education / Licensure
High school diploma or GED
Knowledge of Medical terminology, coding, indexing and legal aspects of health information helpful
Qualifications / Experience
Minimum of 2 years management experience
Minimum of 2 years managing Medical Records and complying with HIPAA regulations
Ability to use computer data base for Medical Records
Excellent verbal and written skills
Knowledge of Point Click Care helpful
Working Conditions
May encounter frequent interruptions
May be involved with residents, family and government agencies
May be requested to work beyond scheduled working hours at times
Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post‑disaster, etc.)
May be necessary to assist in the evacuation of residents during emergency situations
May be exposed to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses
Physical Requirements
Must be able to move intermittently throughout the day
Repetitive hand motion
Must be able to push, pull, move and or lift up to 25 lbs. to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 15 feet
Ability to read fine print on progress notes and/or medical labels