Medical Records Assistant (Licensed Practical Nurse/LPN)

Position Summary

The Medical Records Assistant (LPN) assists with patients’ clinical records, including coding, auditing, record management, entering physician orders in EHR, clarification and transcription of physician’s orders, and monthly verification of MARs/TARs in accordance with all applicable laws, regulations, and Life Care standards.

Education, Experience, and Licensure Requirements

• Attended an accredited LPN program
• Currently licensed/registered in applicable State. Must maintain an active Licensed Practical/Vocational Nurse (LPN/LVN) license in good standing throughout employment.
• Prior medical records experience preferred

Specific Job Requirements

• Demonstrate knowledge of State and Federal legal requirements relating to documentation, confidentiality, and legal issues pertaining to health information
• Effectively communicate with physicians, nursing staff, and allied health personnel
• Demonstrate efficient usage of complex computer software systems
• Advanced knowledge in field of practice
• Make independent decisions when circumstances warrant such action
• Knowledgeable of practices and procedures as well as the laws, regulations, and guidelines governing functions in the post acute care facility
• Implement and interpret the programs, goals, objectives, policies, and procedures of the department
• Perform proficiently in all competency areas including but not limited to: patient rights, and safety and sanitation
• Maintains professional working relationships with all associates, vendors, etc.
• Maintains confidentiality of all proprietary and/or confidential information
• Understand and follow company policies including harassment and compliance procedures
• Displays integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training

Essential Functions

• Accurately audit and complete ongoing reviews of all patients’ clinical records to ensure documentation and performance compliance
• Accurately maintain current, overflow, and discharged record filing system
• Understand and apply LTC payment systems, including Medicare
• Apply the use of ICD 10 CM coding
• Enter physician orders in EHR
• Contact physician and clarify documents and transcribe orders correctly and efficiently
• Verify accuracy of monthly MAR/TAR prior to end of month reconciliation
• Understanding of HIPAA requirements
• Exhibit excellent customer service and a positive attitude towards patients
• Assist in the evacuation of patients
• Demonstrate dependable, regular attendance
• Concentrate and use reasoning skills and good judgment
• Communicate and function productively on an interdisciplinary team
• Sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
• Read, write, speak, and understand the English language

An Equal Opportunity Employer