Medical Records Coordinator

Job Purpose

Absorbs authority, responsibility, and accountability for record keeping procedures and storage of all clinical records in compliance with facility policies and procedures, professional standards, and state and federal laws and regulations for long-term care facilities.

About the Role

Establishes and implements policies to ensure that records are complete, accurately documented, and readily accessible and systematically organized.

Responsibilities

• Ensures all clinical records contain sufficient information to identify the resident; a record of the resident’s assessments; the plan of care and services provided; the results of any preadmission conducted by the State, and progress notes.
• Initiates and participates in the development of facility policies and procedures to ensure that medical records are complete, accurately documented, readily accessible and systematically organized.
• Develops and implements record storage and retrieval system that complies with applicable record retention laws and maintains accessibility of records.
• Inspects closed records for completeness. Systematically organizes closed medical records for long-term storage.
• Reports delays in completing records to Nursing Home Administrator.
• Develops and maintains appropriate safeguards against unauthorized access and use of computer-based medical records.
• Evaluates medical records for and record format. Makes recommendations for change to continuously improve quality of facility records and records keeping practices.
• Evaluates, through record reviews of open and closed records, compliance with medical record documentation policies. Reports findings to Nursing Home Administrator and Director of Health Services.
• Develops and conducts educational programs for facility staff to explain and discuss documentation policies and practices. Provides training and staff development opportunities to ensure that staff can distinguish between confidential/non-confidential information and release information only in compliance with facility policies.
• Maintains, updates and distributes the lists of facility approved abbreviations and definitions. Provides access to all records pertaining to residents (including current medical record) within 24 hours of oral or written request of resident or legal representative. Makes copies available within 2 working days of request.
• Develops and implements safeguards against loss, destruction, unauthorized access or use of clinical record information including procedures to maintain confidentiality of all information contained in resident’s record and to obtain authorized consents to release information. Releases information without written consent or legal representative only when required by law.
• Advises Administration, physicians, facility staff on applicable requirements regarding the control, use and release of clinical information. Advises administration on ways to safeguard confidentiality of medical records of facility staff.
• Counsels and directs staff in matters of conduct and disclosure during long-term care surveys. Demonstrates concern for identified problems and undertakes corrective action while survey is in progress if appropriate. Fathers and presents supplemental documentation to avoid potential deficiencies. Collaborates with Nursing Home Administrator to develop responses to survey report as needed.
• Maintains current skills and knowledge through continuing education. Applies information to job responsibilities. Performs other duties as assigned by supervisor.

Qualifications

• High school diploma or equivalent.
• A minimum of 1 year of experience as medical records practitioner in long-term care facility.
• Possession of current certification as an Accredited Records Technician. Certification as Registered Records Administrator preferred.

Benefits

Family Makes Us Stronger. Our family, your family, one family. Committed to loving, giving, and caring. United in making a difference. We are eager to connect with you!

Schedule

Full-time

Shift

1st Shift