Medical Records Coordinator

Medical Records Coordinator

Grundy Care Center

Job position

Working at Arboreta Healthcare is more than a job. Our team members are the heart and soul of our facilities, providing our patients and residents with compassionate care, attention, and a sense of belonging to a community of 34 facilities and 3100 employees. We are looking for a Medical Records Coordinator to join our team at Grundy Care Center!

Position Summary

The primary purpose of Medical Records Coordinator is to maintain Medical Records in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete Medical Records program is maintained.

Duties/Responsibilities

Customer Service

• Demonstrates positive customer service when performing the role of the Medical Records Coordinator, with residents, family members, facility staff and medical staff.

• Displays flexibility, team spirit, compassion, respect honesty, politeness and accountability when dealing with residents, family members and facility staff.

• Demonstrates an awareness of and sensitivity for residents’ rights in all interfaces with residents and family members.

• Communicates effectively via open, straightforward communication, including use of listening skiffs and by accessing the appropriate chain of command

. • Seeks validation of knowledge base, quality, decision-making and skill level by actively questioning when necessary.

• Participates in interdisciplinary communication activities; actively listens and actively contributes.

Administrative Functions:

• Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.

• Assist in organizing, planning and directing the Medical Records section in accordance with established policies and procedures.

• Assist in the orientation program for all personnel in accordance with our policies and procedures

. • Assist the Medical Records Consultant as required

• Maintain minutes of meetings/files as necessary.

• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that Medical Records can be property maintained.

• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.

• Collect, assemble, check and file resident charts and personnel records as required.

• Ensure that schedules are followed as outlined for respective shift/area.

• Ensure incomplete records/charts are returned to nursing service for correction.

• Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.

• Follow established policies and procedures for the Medical Records section.

• Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.

• Maintain a record of authorized information taken from charts/records, i.e., type information, name of recipient, date, department etc.

• Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.

• index Medical Records as directed by the Medical Records consultant.

• Maintain various registries as directed including register for admission and discharge of residents.

• Type reports for physicians as necessary.

• Collect charts, assemble them in proper order, and inspect them for completion.

• Perform miscellaneous duties pertaining to Medical Records and assist business office personnel as required/directed.

• Assist in admission, transfer, and discharge procedures as necessary.

• Answer telephone inquiries concerning Medical Records functions. Prepare written correspondence as necessary.

• Retrieve Medical Records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.)

• Assure that Medical Records taken from the department are signed out and signed in upon return to the department.

• Index Medical Records as directed.

• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of the Medical Records Clerk.

• Other related duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility.

Committee Functions:

• Perform secretarial duties for committees of the facility as directed.

• Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.

Staff Development:

• Attend and participate in in-service educational classes and on-the-job training programs including annual OSHA and CDC in-service training programs concerning hazard communication, TB management and blood-borne pathogens.

• Attend and participate in workshops, seminars, etc., as approved.

RESIDENT RIGHTS

• Maintain confidentiality of all pertinent resident care information to assure resident rights are protected.

• Assure that residents' rights to fair and equitable treatment self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints, are followed.

EXPENSE CONTROL

Budget and Planning Functions

• Keep abreast of economic conditions/situations and recommend to the Medical Records Designee/Coordinator adjustments in nursing services that ensure the continued ability to provide quality care.

Required Skills/Abilities

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

• Must possess the ability to make independent decisions when circumstances warrant such action.

• Must possess the ability to deal tactfully with personnel, residents, visitors and the general public.

• Must be knowledgeable of medical terminology.

• Must possess the ability to work harmoniously with other personnel.

• Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices.

• Be able to follow written and oral instructions.

• Possess basic computer knowledge and the ability and aptitude to learn software.

• Must not pose a direct threat to the health or safety of other individuals in the workplace.

Education and Experience

• Must possess, as a minimum, a high school diploma.

• Must be able to type a minimum of 45 words per minute, use citation equipment, and have a working knowledge of medical terminology.

• Must have administrative experience and/or experience as a CNA or Nurse at a level necessary to accomplish the job.

• On-the-job training provided in medical record procedures.

Physical Requirements

• Must be able to move intermittently throughout the work day.

• Must be able to speak and write the English language in an understandable manner.

• Must be able to cope with the mental and emotional stress of the position.

• Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.

• Must function independently, have personal integrity, have flexibility, and the ability to work effectively with other personnel.

• Must meet the general health requirements set forth by the policies of this facility which include a medical and physical examination.

• Must be able to push, pull, move, and/or lift a minimum of 30 pounds to a minimum height of waist height and be able to push, pull, move, and/or carry such weight a minimum distance of 20 feet.

• May be necessary to assist in the evacuation of residents during emergency situations.

Work Environment

• Works in office areas as well as throughout the facility.

• Moves intennltten6y during working hours.

• Is subject to frequent interruptions.

• Works beyond normal working hours, weekends and holidays and on other shifts/positions as necessary.

• Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).

• Attends and participates in continuing educational programs.

• Is subject to injury from falls, bums from equipment, odors, etc., throughout the day, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.

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

• Communicates with nursing personnel, and other department personnel.

• Is subject to hostile and emotionally upset residents, family members, personnel, visitors, etc.

• Is involved with residents, family members, personnel, visitors, government agencies and personnel, etc., under all conditions and circumstances.

• May be subject to the handling of and exposure to hazardous chemicals.