Medical Records

Responsibilities

• Performs routine audits of in-house charts upon admission and at least quarterly, to ensure completeness and accuracy.
• Completes focus audits and PI audits on specific topics as directed by Administrator or Regional Medical Records Director.
• Provides notification to the staff on deficiencies found in the record and does follow-up to ensure the in-house records are complete.
• Assembles the medical records of discharged residents.
• Analyzes discharged charts for completeness and follows up with staff and physicians to ensure discharged records are completed.
• Processes requests for medical information as directed by the Administrator, Regional Medical Records Director and/or corporate Risk Manager (i.e., requests from residents, attorneys, for insurance reimbursement, in response to a subpoena).
• Maintains Release of Information Log for all requests for medical records and copies released for payment, continuity of care, and health care operations.
• Completes Accounting of Disclosures form according to HIPAA policies and files in resident’s chart.
• Maintains the confidentiality of medical records by ensuring confidentiality of health information.
• Makes sure physicians visit the facility and reports non-compliance to the DON/Administrator at least monthly.
• Purges charts, maintains destruction log, and maintains information for records at off-site storage facility.
• Sets ICD-9 CM codes for resident diagnoses. Inputs diagnoses and codes in HCS system.
• Collaborates with outside transcription company for physician dictation.
• Fills out loose sheets needed to be attached to the record.
• Maintains supply of forms in department and on nursing units.
• Completes discharge/transfer notice when necessary for transfers to hospital or expired residents.
• Inputs discharge/transfer data in HCS system and ECS.
• Forwards requested records to Carespring Case Manager for managed care updates.
• Serves as facility contact person to oversee Record Retention and Destruction Policy working with each department as documents/records are boxed for long term storage.
• Sign-off on each Record Log to confirm proper completion.
• Performs other duties as assigned.

Qualifications

• Maintains or is willing to obtain Medical Records Certification.
• Detail oriented person and can complete tasks on a need based schedule.
• PointClickCare experience is preferred.
• Knowledge of Microsoft Word, Excel highly encouraged.