Medical Records Specialist

14 hours ago


Tucker, Georgia, United States ResCare Community Living Full time

ResCare Community Living is seeking a skilled Medical Records Specialist to join our team. As a Medical Records Specialist, you will be responsible for providing routine care and general observation of clients' health status. You will assist the RN and physician in treatments and communicate with clients and their families/guardians. You will also communicate health/nursing needs and/or recommendations to the RN supervisor. Additional responsibilities include assisting in medical/health appointments as needed, ensuring the provision of nursing/health services under the direction of the RN and as ordered by the physician, and reporting pertinent information and changes in individual health status to attending physician/health professionals and to the Team as needed in a timely manner. You will also ensure the provision of needed adaptive equipment, administer medications, verify the correct medications are administered, and that clients' response to medications is noted and documented along with any noted side effects. You will work closely with home/facility/pharmacy staff in consulting on psychotropic medications, side effects, and medication reviews. You will also dispose of unused medication per policy and check the medication cabinet on a weekly basis to ensure medications are administered as ordered, appropriately documented on the MAR, and that missed medications are documented, and required follow-up occurs. You will also check program/service areas on a frequent but not less than a monthly basis to ensure the necessary medical/nursing/medication supplies are available and in ample supply. You will report client illness, potential communicable diseases or infections and work closely with RN, direct care staff, other programmatic and health care professionals, and family in maintaining a safe environment for clients and staff. You will ensure health status, care and services are documented accurately and timely per company and state requirements. You will provide supervision and education for non-licensed staff in the provision of care and services and report any changes. You will complete a quarterly nursing evaluation/review of body systems on assigned individuals per program requirements. You will ensure incidents are recorded, the individual is safe, receives required medical care, communicates to RN, operations leadership timely. You will participate in clinics completed at the operation with PCP, psych, etc. Participate in on-call duties to ensure weekend and after-hours access to clinicians by staff and individuals served (participates in on-call rotation as assigned). You will participate in quarterly quality improvement activities, weekly team/staff meetings and Interdisciplinary Team meetings (IDT/PDP). You will transcribe physician phone orders and other medically related reports. Work hours may vary – weekends and evening shifts/visits may be required. Completion of a state approved training program (e.g., Must have at least 6 months of direct nursing experience. Experience in providing services and supports to individuals with developmental disabilities, or related disorders preferred. Valid driver's license, with a satisfactory driving record, as defined by ResCare's vehicle policy. Must have the ability to use a computer utilizing company documentation systems. ResCare Community Living has four decades of experience in the disability services field, providing support to individuals who need assistance with daily living due to an intellectual, developmental or cognitive disability. Our community living services are provided in 27 states with several thousand programs and a comprehensive range of high-quality services, including: Community Living, Adult Host Homes for adults regardless of disability, Behavioral/Mental Health Support, In-home Pharmacy Solutions, Telecare and Remote Support, Supported Employment and Training Programs, and Day programs. Follow us on Facebook and LinkedIn.



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