MEDICAL RECORDS

Job Summary
• Protects the security of medical records to ensure that confidentiality is maintained.
• Reviews records for completeness, accuracy and compliance with regulations.
• Compiles and maintains patients' medical records to document treatment, physician orders, nursing notes, etc.
• Enters data, such as demographic characteristics, history and extent of disease, diagnostic procedures and treatment into computer.
• Plans, develops, maintains, and operates a variety of health record indexes and storage and retrieval systems to collect, classify, store and analyze information.
• Identifies and compiles patient data using standard classification systems.
• Resolves/clarifies codes and diagnoses with conflicting, missing, or unclear information by consulting with the nursing facility staff or others to get additional information
• Purges records as per policy
• Orders & receives office supplies and medical forms, journals, books, etc.
• Participates in staff meetings and new employee orientation and training programs.
• Performs maintenance functions for the department computer system.
• Assists in maintaining and fostering customer relationships.

Qualifications:
• At least two years’ experience working in long-term care.
• Experience in computer operations required.
• Associate in Science degree in medical records preferred or certification as medical coder preferred.
• Must demonstrate the ability to read, write and speak English.
• Must demonstrate ability to work independently, without direct supervision, within established policies.
• Must have demonstrated effective skills both in writing and verbal communication.
• Must have effective interpersonal skills.
• Must be able and willing to travel to customers/facilities as needed.

Physical Requirements and Working Conditions:
Will meet all physical requirements of the position as identified by the facility policies and procedures
related to functional job analysis.

Other Duties:
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.