Medical Records Coordinator

Purpose of Your Job Position

The primary purpose of your position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines as well as in accordance with our Facility’s established privacy policies and procedures.

Delegation of Authority

As Medical Records Coordinator you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Function

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is an essential function of the position.

Duties and Responsibilities

Administrative Functions

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

• Assist in organizing, planning, and directing the medical records department in accordance with established policies and procedures.

• Assist the Facility medical personnel, as required.

• Develop and maintain a good working rapport with other departments within the Facility, to assure that medical records can be properly maintained.

• Retrieve resident records (manually and electronically). Deliver as necessary.

• Files information such as nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.

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

• Ensure incomplete records and charts are returned to appropriate departments or personnel for correction.

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

• Ensure all residents records are coded, stored, completed correctly, and maintained in a confidential manner.

• Responsible for closure of discharged resident records. Prepare record for closure by organizing the record in an orderly fashion, bind the record, and review record for completeness. Works with nursing department for closure.

• Tracks and monitors release of discharge resident records and thinned records to interdepartmental personnel and physicians.

• Complete thinning or resident records in a timely manner to maintain appropriate forms on the record and delete those that are not needed on the active file.

• Maintain thinned material from resident records in a neat and orderly manner. Review thinned material for completeness. Storage of thinned information in the station file cabinet on medical records in a neat and orderly fashion.

• Ensure physician orders are signed within a timely fashion.

• Maintain Credentialing and Privileging records for physicians.

• Ensure Death Certificates are included in closed charts and notify nursing if missing.

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

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

• Abstract information from records as authorized and required for insurance companies, Medicare, Medicaid, VA, etc. in accordance with current Privacy Rules.

• Index medical records as directed by the medical records and health information consultant.

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

• Assist the Quality Assessment and Assurance Coordinator in developing, implementing and maintaining an ongoing quality assurance program for medical records.

• Assist the Quality Assessment and Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies.

• Participate in QA/QI meetings on a monthly and/or quarterly basis.

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

• Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas, as necessary.

• Must adhere to all HIPAA requirements.

Staff Development

• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.

• 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.

• File active and inactive records in accordance with established policies.

• Index medical records, as directed.

• Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.

• Report any known or suspected unauthorized attempt to access Facility’s information system.

• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of this position.

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

Committee Functions

• Attend and participate in mandatory Facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, etc.).

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

Safety, Equipment and Supply Functions

• Report all unsafe and hazardous conditions, defective equipment, etc., to your supervisor immediately.

• Ensure supplies have been replenished in work areas, as necessary.

• Assure that work assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of workday, etc.

Working Conditions

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

• Attends and participates in continuing educational programs.

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

• Communicates with nursing personnel, and other department personnel.

Education

• Must possess a high school diploma or GED.

Experience

• One (1) years’ experience in medical records.

• A working knowledge of medical terminology, anatomy, and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required.

Specific Requirements

• Must be able to type.

• Must be able 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 minimize waste of supplies, misuse of equipment, etc.

• 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.

• Be knowledgeable in computers, data retrieval, input and output functions, etc.

Physical and Sensory Requirements

(With or Without a Reasonable Accommodation)

• Must be able to move intermittently throughout the workday.

• Must possess sight and 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 meet the general health requirements set forth by the policies of this Facility, which may include a medical and physical examination.

• Based on the Occupational Safety and Health Administration's Guidelines for Nursing Homes Ergonomics for the Prevention of Musculoskeletal Disorders and the American Conference Governmental Industrial Hygienists' Threshold Limit Values for Lifting the Facility has identified that this job may require the lifting of residents, equipment, or other objects. Accordingly, this job may require a minimum of 5 pounds and a maximum of 25 pounds lifting, periodically and or as needed.

Benefits:

• Health insurance
• Dental insurance
• Vision insurance
• Health savings account
• Life insurance
• Paid time off
• 401(k)