The primary purpose of this position is to maintain medical records in accordance with federal and state guidelines, and in accordance with our policies and procedures, to assure that a complete medical records program is maintained.
Assist in organizing, planning & directing the medical records section in accordance with established policies and procedures.
- Maintain a working rapport with other departments in the facility to assure that medical records can be properly maintained.
- Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
- Collect, assemble, check, and file resident charts and personnel records as required.
- Ensure incomplete records/charts are returned to nursing service for correction.
- Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.
- Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
- Maintain records of information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
- Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
- Maintain various registries as directed including register for admission and discharge of residents.
- Collect charts, assemble them in proper order, and inspect them for completion.
- Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
- Assist in admission, transfer and discharge procedures as necessary.
- 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, etc.)
- Assure that medical records taken from the department are signed out and signed in upon return to the department.
- Index medical records as directed.
- Other duties and responsibilities that may become necessary or appropriate to meet the administrative needs of the facility.
- Must possess, as a minimum, a high school diploma or equivalent.
- Must have knowledge of medical terminology
- Must possess a current, unencumbered, active license to practice as an RN or LPN in this state.
- Must be able to read, write, speak, and 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, family members, visitors, government agencies/personnel, and the general public.
- Must possess the ability to plan, organize, develop, implement, & interpret programs, goals, objectives, policies & procedures, etc., that are necessary for providing quality care.
- Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.
How To Apply