Fay Medical Records Coord LTC

About the Role

Independently uses own judgment and discretion to manage activities of the Long-Term Care (LTC) Health Information Management (HIM) functions, including planning and organizing documentation, storage, and retrieval of resident medical records. Ensures accurate and timely documentation while overseeing quality and productivity of medical records in active, overflow, and discharged charts.

Responsibilities

• Assign ICD-10-CM codes to all LTC patient records in accordance with system and federal requirements.
• Ensure all practices meet State and Federal regulations, including HIPAA compliance for the protection of resident’s Protected Health Information (PHI).
• Develop and maintain policies and procedures for LTC resident medical records to assure compliance with regulations.
• Organize and plan the LTC medical records department in accordance with established policies.
• Process all release of information (ROI) requests for the LTC facility and log requests into the Expanse ROI Desktop.
• Assure the collection, assembly, and filing of resident charts to maintain proper order and secure storage.
• Maintain systems for filing, retention, and destruction of records to prevent loss, destruction, or unauthorized use.
• Contact physicians regarding telephone orders, timely visits, and documentation requiring signatures or dictation.
• Conduct routine monitoring of LTC medical records for compliance with State and Federal regulations, including admission/re-admission, concurrent/quarterly, MDS, diagnoses, acute problems, and discharge information.
• Calculate and report monthly deficiency rates to the QA Committee, including trending and analysis of identified issues, and document corrective action plans.
• Assist in developing and implementing action plans for identified documentation problems or concerns.
• Maintain master patient index information for the facility.
• Adhere to DCH Standards, including performance, patient and employee satisfaction, and financial standards.
• Perform compliance requirements as outlined in the Employee Handbook and adhere to DCH Behavioral Standards.
• Ensure safety for patients, visitors, and employees by identifying and reducing unsafe practices.
• Use electronic mail, time and attendance software, learning management software, and intranet as required.
• Perform all other duties as assigned.

Requirements

• Prior medical record experience in a Long-Term Care Facility or hospital Health Information Management (HIM) department required.
• Knowledge of ICD-10-CM coding required.
• Understanding of medical terminology required.
• Knowledge of regulations, accreditation standards, state minimum standards, and professional standards for health information in long-term care preferred.
• Proficiency in Microsoft Word and Excel required.
• General office skills, including filing and organizing, required.
• Good customer service and telephone skills.
• Knowledge of documentation and legal issues mandated by HIPAA preferred.
• Strong oral and written communication skills required.
• Ability to read, write legibly, speak, and comprehend English.
• Positive attitude toward the elderly is necessary.

Qualifications

Associates degree, LPN certificate, RHIA, or RHIT preferred (required if hired after 11/1/2016).

Working Conditions

• Must be able to work independently and withstand pressures of constant deadlines, audits, educational demands, and a changing healthcare environment.
• Ability to deal with angry customers, both internally and externally.
• Must communicate verbally and in writing on a daily basis.
• Ability to lead and participate in groups, including making frequent presentations.
• Must adapt to changes in the work area as assigned.
• Stressful environment working closely with physicians and meeting frequent high-pressure deadlines.

Physical Requirements

• Light work position requiring the ability to exert up to 20 pounds of force occasionally and/or up to 10 pounds frequently.
• Prolonged periods of sitting.
• Must be able to kneel, sit, crouch, or stoop with good balance for extended periods.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.
• Must be able to perform duties with or without reasonable accommodation.