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Medical Records Coordinator
4 months ago
Moorings Park is looking for a Medical Record Coordinator. The Medical Records Coordinator is responsible for performing the clerical duties of the Medical and Nursing Departments to ensure that documentation for all medical record information is in compliance with established facility policies and procedures, and State and Federal regulations.
Contributions:
Health Information Management Functions:
- Maintains the security of health information systems and medical records. Assures physical protection is in place to prevent loss, destruction and unauthorized use of both manual and electronic records. For example, ensures safeguards are in place such as sign-out systems, and systems for securing file cabinets and file room where overflow and discharge records are stored.
- Assures systems are in place to maintain confidentiality of manual health information.
- Manages the release of information functions for the facility including review and processing of all requests for information. Maintain facility policies and standards of practice to assure release of information requests are appropriate and meet legal standards and is processed in accordance with facility policies and procedures.
- Maintains a forms management system for development, review, and reproduction of facility forms for Disaster Recovery.
- Maintains systems for filing, retention and destruction of overflow records and discharge records in accordance with facility policy and relevant regulations.
- Participates in Triple Check PDPM monthly meeting and other meetings, as needed.
- Ensures systems are in place to maintain up to date resident-specific information in the computerized clinical information system and completes data entry functions as applicable.
- Ensures compliance with applicable regulations related to documentation of Advance Directives.
- Ensures all resident admissions are compliant with applicable rules and regulations.
Records Management Functions:
- Initiates the Chateau resident medical record and in house overflow file for thinned charts, prepare labels, etc.
- Completes admission checklists and admission audits.
- Conducts concurrent audits/quality monitoring at regular scheduled intervals.
- Runs monthly unlocked documents report and sends emails/notes to partners/providers regarding unlocked assessments/notes.
- Contacts physicians or departments as needed when signatures or information is needed before records can be completed.
- Maintains a monthly monitoring system to assure physician orders and other information is signed or completed by the physician as needed.
- Updates Medicare Minutes on a daily basis. Adds new and readmitted residents and removes discharged residents and residents on leave.
- Maintains Medicare "Certification/Recertification" forms and follows up with physicians for signature.
- Uploads hospice CTI certification and recertification, POC, and admission agreement documents into EMR on an ongoing basis for residents on hospice care. Maintains an updated list to track needed and uploaded documents.
- Thins medical records from charts in nurses' stations in accordance with the written policy and procedure and files thinned records in the overflow files in the Medical Records office.
- Uploads hospital records into EMR for new admissions and readmissions.
- Uploads paper and electronic medical records for active and discharged residents (labs, consult notes, orders, etc.).
- Updates discharge information on Master Discharge Log (Excel spreadsheet).
- Updates the discharge record control log and monitors discharge record processing status.
- Obtains discharge charts from the nurses' stations and assembles the charts with the overflow files in established discharge order.
- Analyzes the record for deficiencies using the discharge record audit/checklist.
- Destroys old medical records per policy.
Job Requirements:
- Excellent oral and written communication skills in the English language required
- During emergencies or natural disasters may be required to be on duty for the duration of the disaster.
- Associate's Degree in Health Information Management.
- Registered Health Information Technician (RHIT) certification is required.
- Experience in Release of Information.
- Long term care or healthcare experience as a coordinator of Health Information in another facility is preferred.
- Knowledge of medical terminology.
Moorings Park ® Communities, a renowned Life Plan organization includes three unique campuses located in Naples, Florida. We offer Simply the Best® workplaces through a culture of compassionate care for both our residents and our partners.
Simply the Best Benefits for our partners include:
- FREE health and dental insurance
- FREE Telemedicine for medical and behavioral health
- Vision insurance, company paid life insurance and short-term disability.
- Generous PTO program
- HSA with employer contribution
- Retirement plan with employer match
- Tuition reimbursement program
- Wellness program with free access to on-site gym
- Corporate discounts
- Employee assistance program
- Caring executive leadership