Medical Records Coordinator

Grossmont Gardens Senior Living
Job Description

Position Title: Medical Records Clerk

Department: Medical Records

Reports To: Director of Nursing/Administrator

FLSA Status: Non-exempt

Effective Date: June 2016

Position Summary

Assists the Director of Nursing or other designated supervisor in implementing facility health information (medical record) policies and procedures and to organize and maintain a system in compliance with local, state and federal requirements. Completes assigned duties in an organized and accurate manner to help meet the department objectives.

Supervisory Responsibilities

This job has no direct Supervisory responsibilities

Essential Duties (Supervisor: Enter N/A for any task not assigned)

Responsible for completing the following duties as delegated and directed by the

Supervisor:

• Protect all medical record information from loss, defacement or destruction before retention period ends.
• Maintain confidentiality for all resident information and Medical Records.
• Implement the system of record keeping and retention as per facility policies and procedures.
• Maintain a master filing system for identification of resident information. Index Medical Records as directed.
• Maintain a discharge analysis and disease index as required.
• Maintain a record of authorized information released from charts/records, i.e., type of information, name of recipient, date, department, etc.
• Maintain various registries, as directed, including register for admission and discharge of residents.
• Verify census daily; prepare and distribute census reports to the designated individuals, if directed.
• Process admission and discharge records timely and accurately. Complete all information on admission records and place in the medical record as directed.
• Complete identification on forms in the residents’ medical record, if assigned.
• Assist with data entry, printing, processing or transmitting computer information or forms.
• Assist with the Quality Assurance / Quality Indicator process as directed.
• File information such as nurses’ notes, resident assessments, progress notes, physician orders, laboratory reports, x-ray results, correspondence, etc., into records.
• Collect, assemble, check and file resident records as directed.
• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.
• File active and inactive records in accordance with the established policies.
• File Medical Records promptly and accurately.
• Retrieve resident records (manually/ electronically) and deliver to the authorized individuals as necessary.
• Abstract information from records as directed for insurance companies, Medicare,

Medicaid, etc in accordance with current Privacy Rules (HIPAA).

• Prepare records in answer to subpoenas, audits and other medical record requests as directed.
• Inform the Administrator or designated supervisor of any record information requests including, but not limited to, copies of open or closed records, subpoenas or any other form of request by a resident/ responsible party, agency or outside source.
• Request copies of necessary information from the medical record of referral sites or other sources as requested.
• Review all records for incomplete, delinquent or missing documentation by appropriate personnel or health care professionals.
• Report all incomplete or problematic record audit findings to the appropriate supervisors.
• Mail forms to the physicians for completion as directed.
• Monitor the Medicare certification/ recertification process to obtain physician signatures as appropriate and as directed.
• Manage overflow (i.e. thinning) from in-house records and file per the established protocol.
• Audit transfer/discharge information for accuracy and completeness.
• Complete any reports of record reviews and submit them to the designated individual or as directed.
• Follow up on incomplete record findings and notify appropriate supervisory staff or as directed.
• Make diligent efforts to have a completely audited and intact medical record before closing.
• Develop and maintain a good working rapport with inter-department personnel, as well as other departments, within the facility to assure that Medical Records are properly maintained.
• Perform other duties as assigned.

Qualifications

High School Graduate as a minimum. Must be detail oriented and possess good organizational and accuracy skills.

Competencies

To perform the job successfully, an individual should demonstrate the following

competencies:

Must be able to read, write, speak, understand the English language and be able to communicate effectively.

Must possess the ability to seek assistance when circumstances warrant.
Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.

Must possess ability and willingness to work harmoniously with other personnel.
Must have patience, tact, cheerful disposition, display enthusiasm and be able to cope with the mental and emotional stress of the position.
Must be able to tolerate fast pace: time demands and frequent interruptions and be adaptable to changes.

Physical Requirements

Must be able to move intermittently throughout the work day.
Must be able to lift, grasp and use office equipment.
Must be able to listen and speak with individuals and groups while performing the duties of this job
Is required to stand, use hands, and reach with hands and climb or balance.
Must be able to push, pull, move and or lift a minimum of 25 pounds to a minimum height of 3 feet.
May be necessary to assist in the evacuation of residents during emergency situations.

Job Type: Full-time

Pay: $18.00 - $20.00 per hour

Expected hours: 40 per week

Benefits:

• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Ability to Relocate:

• La Mesa, CA 91942: Relocate before starting work (Required)

Work Location: In person