POSITION TITLE: MEDICAL RECORDS

DEPARTMENT: Administration

REPORTS TO: Administrator

POSITION SUMMARY:

· Comply with standards of business conduct in accordance with federal, state and local health and regulatory standards and guidelines, as applicable.

· Must possess, at a minimum, a high school diploma or a GED or at least two (2) years of experience in the healthcare field and/or related industry.

· Must be able to work well with peers in a congenial work environment, and above all, maintain the utmost compassion and dignity to the residents and adhere to the Resident Bill of Rights.

· Must be able to work beyond normal working hours; on weekends, as well as holidays, to the extent necessary. On-call status is a function of the job and employee understands, agrees to, and acknowledges that schedule flexibility is for the betterment of the residents and that the Business Coordinator will make themselves available, as needed, to ensure proper staffing levels.

· In exigent circumstances, the employee may be subject to call back during emergency conditions (e.g., severe weather,

evacuation, temporary staffing shortages, etc.).

· Must adhere to Windsor Health Care, LLC's attendance policies and follow the terms and conditions of employment as set forth in the Employee Handbook.

· Must be able to read, write, speak and understand English.

· Must maintain the highest standards in caring and servicing the needs of the residents and residents' family members and loves ones.

· Must adhere to all facility policies and procedures.

RESPONSIBILITIES/ACCOUNTABILITIES:

· Maintains accurate order of open charts;

· Types physician’s orders/transcriptions as needed;

· Prepares closed charts;

· Assumes responsibility for diagnostic admission and discharge coding index;

· Ensures that all Admission Orders are signed by the attending physician in a timely manner;

· Ensures all Medicare Certifications and Re-certifications are signed in a timely manner;

· Notifies MDs in reference to compliance of resident visits and progress notes;

· Communicates with Pharmacy in reference to additions/deletions of resident MARs, POSs;

· Assists nursing staff with monthly editing;

· Initiates yearly flu/pneumonia vaccine program and maintains accurate record keeping;

· Answers telephone inquires and may answer correspondence;

· Performs miscellaneous duties pertaining to medical records;

· Writes, types and distributes advance notices for admissions, re-admissions, room changes, any status changes, discharges, etc. to appropriate facility staff;

· Obtains all appropriate departmental and physicians’ signatures on discharge charts within 30 days of discharge;

· Performs other duties as requested.

· Report any occupational exposures to blood, body fluids, infectious materials, and or hazardous chemicals in accordance with facility policy;

· Report work related injuries and illnesses immediately to your supervisor;

· As a condition of employment, complete all assigned training and skills competency;

· Participate in all life safety and emergency drills and trainings;

· Fulfill responsibilities as assigned during implementation or activation of the facility’s emergency plan;

· Assists with evacuation of residents in an emergency situation;

· Maintain confidentiality of Protected Health Information, including verbal, written and electronic communications;

· Report non-compliance with policies, procedures, regulations or breaches in confidentiality to appropriate personnel.

· Protect residents from abuse, and cooperate with all investigations;

· Report any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to supervisor and/or administrator;

· Report any retaliation or discrimination to the Human Resource Director and the Compliance Officer;

· Fulfill individual responsibility to report any suspicion of a crime to law enforcement and the state agency;

ANNUAL HEALTH REQUIREMENTS:

· Must provide annual verification of a negative TB skin test.

· Proof of full COVID-19 vaccination required with exceptions for medical and religious accommodations.

PHYSICAL AND SENSORY REQUIREMENTS:

(With or Without the Aid of Mechanical Devices)

· Must be able to move intermittently throughout the workday.

· Must be able to cope with the mental and emotional stress of the position.

· Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.

· Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination.

· Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, agitated residents

· Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet.

· May be necessary to assist in the evacuation of residents during emergency situations.

Job Type: Part-time

Expected hours: 20 per week

Benefits:

• Dental insurance
• Health insurance
• Paid time off

Schedule:

• Monday to Friday

Experience:

• Medical records: 1 year (Required)

Ability to Commute:

• Wayne, NJ 07470 (Required)

Ability to Relocate:

• Wayne, NJ 07470: Relocate before starting work (Required)

Work Location: In person