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Medical Records Specialist

2 months ago

Tucker, Georgia, United States ResCare Community Living Full time
Job Summary

We are seeking a skilled Medical Records Specialist to join our team at ResCare Community Living. As a Medical Records Specialist, you will play a critical role in ensuring the provision of high-quality nursing and health services to individuals with developmental disabilities.

Key Responsibilities
  • Provide routine care and general observation of clients' health status
  • Assist RNs and physicians in treatments and communicate with clients and their families/guardians
  • Communicate health/nursing needs and/or recommendations to RN supervisors
  • Assist in medical/health appointments as needed
  • Ensure the provision of nursing/health services under the direction of the RN and as ordered by the physician
  • Administer medications, verifying the correct medications are administered and that clients' responses to medications are noted and documented
  • Work closely with home/facility/pharmacy staff in consulting on psychotropic medications, side effects, and medication reviews
  • Dispose of unused medication per policy
  • 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
  • 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
  • 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
  • Ensure health status, care, and services are documented accurately and timely per company and state requirements
  • Provide supervision and education for non-licensed staff in the provision of care and services and report any changes
  • Complete a quarterly nursing evaluation/review of body systems on assigned individuals per program requirements
  • 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
  • Participate in quarterly quality improvement activities, weekly team/staff meetings, and Interdisciplinary Team meetings (IDT/PDP)
Requirements
  • Completion of a state-approved training program
  • 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
  • Ability to use a computer utilizing company documentation systems
About ResCare Community Living

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.