Medical Records Director at SNF

About us

We are hiring a Medical Records Director for a small Skilled Nursing Facility located in Sacramento, Ca. THIS POSITION WILL BE TEMPORARY FOR 3 MONTHS.

ESSENTIAL JOB FUNCTIONS:

• Perform health record maintenance duties; assembling, labeling, cleaning, filing and purging documents
• Maintain stock of forms and record supplies
• Request necessary resident information from transferring facilities
• Process external information requests from authorized institutions and individuals
• Compile statistical data at the direction of Administrator
• Prepare Alirts (OSHPD) yearly report
• Maintain the confidentiality and physical security of health records in accordance with HIPPA rules and regulations
• Perform concurrent and discharge quantitative audits of health records. Physician visit audits. Notification of physician when required by procedure
• Develop and perform specialized audits on a predetermined time sequenced rotation with plan of completion to be defined and time limited. Audit all current resident charts to notate deficiencies and obtain and assist in corrections on a scheduled basis. Submit deficiency reports and to persons responsible for correction with date of completion to be returned (3 days) to the Administrator, Director of Nurses or designated representatives. These audits will include but are not limited to:Admission audits within 24 or 48 hours,
• 7th 14th and 21st daySkin and pressure soresFoley Catheter, Intake and OutputDiabeticSpecial Therapy, i.e., IV, PT, OT, Inhalation, Tube Feeders, etcPsychotropicNursing Weekly Progress NotesBowel and BladderMedications and TreatmentsTelephone OrdersMDS - Initial, Quarterly, Yearly, Change in conditionIntensity of Care DirectivesDischarge ChartsWeights - Weekly/MonthlyADL recordsLab/X-RayMedicare Q shift ChartingCurrent H and PPhysician VisitsPlan of Care - entries of each disciplineChange in condition - DailyQuarterly Progress notes - Activity, Dietary, Social Service, Discharge PlanningAccidents/Incident Reports
• Disease index coding at time of admission, when diagnostic status alters and within 30 days of discharge date. Complete any outstanding disease index coding
• Discharge charts must include the following information prior to filing:Final Diagnosis and/or Death Certificate
• Completed Disease Index CodingObtain all outstanding documentation and required signatures to meet criteria mandated by facility policy
• Mail telephone order forms to physicians daily, assure prompt return and file in chart
• Prepare Physician Orders, Medication/Treatment records, ADL records and Resident Care Plans for accurate input into computer and printing on scheduled basis
• Perform computer operation functions including regular input of data and printing on a scheduled basis
• Keep computer terminal(s), keyboard(s) and office clean and functional
• Maintain appropriate medical record storage and destruction of medical records consistent with facility policy
• Follow-up on reports and recommendations submitted by the Medical Records Consultants
• Report to the Director of Nursing and Administrator significant documentation problems
• Attend and participate in in-service education and staff meetings as required, including risk management and daily stand-up meetings. Maintain minutes of meetings/files as requested
• Be courteous, considerate and cooperative when communication with all facility personnel, resident and public
• React appropriately to emergencies and disaster situations

Job Type: Full-time

Pay: $35.00 - $39.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday
• Weekends as needed

Ability to Commute:

• Sacramento, CA 95822 (Required)

Ability to Relocate:

• Sacramento, CA 95822: Relocate before starting work (Required)

Work Location: In person

Salary : $35 - $39