Medical Records experience required, certification and ICP-10 coding experience preferred. Full time position Monday-Friday, days. Hours can be somewhat flexible, 8 hour a day shift. Reports to DON and Administrator. Must be able to work independently and prioritize job duties.

PURPOSE:

To assure orderliness of current clinical records and oversee timely assembly of closed records, accountable for open and closed records per HIPAA requirements.

DUTIES:

• Proficiently respond and manage the release of health information functions for the facility including the processing and tracking of all requests for medical records information.
• Maintain systems for filing, retention and destruction of overflow/thinned records and discharge records that are compliant with State, Federal and HIPAA guidelines.
• Maintain confidentiality, security and physical safety of health information systems and medical records.
• Complete and maintain the master patient index.
• Complete facility statistical reports as applicable and follow mandatory reporting requirements.
• Support and assist in carrying out corporate compliance initiatives as assigned.
• Initiates the new admission medical record and in-house overflow file, prepare labels, etc.
• Thin in-house records and file in chart order for discharge in the in-house overflow file.
• Obtain the clinical record and auxiliary/overflow records within 24 business hours of discharge or death of a resident.
• Assemble discharge record. Analyze the discharge record for deficiencies (i.e. Physician signatures/notes, labs, etc.) Follow up on incomplete record until completed.
• Maintains record of sign in and sign out log for chart usage at all facility locations (i.e. on each neighborhood, medical record office, etc.
• Maintains a master forms book and a full inventory supply of all forms for chart use, if assigned.
• Code diagnoses at admission, scheduled intervals and upon discharge as assigned.
• Processing and maintaining a legal or litigation hold on records.
• Processes death certificates, burial permits, etc. as needed.
• Conduct audit/quality reviews to verify that information is complete and timely (i.e. Physician signatures and dates). Report findings to the Director of Nursing/Administrator.
• Consistently manages the collection, processing, maintenance, storage, timely retrieval and distribution of health information and medical records.
• Demonstrate competency using current clinical software system.
• Attends all required meetings and functions as requested.