What are the responsibilities and job description for the Medical Records (LPN)/ Social Service Assistant position at Ormond Rehabilitation and Nursing Center?
Ormond Rehabilitation and Nursing Center -
The Medical Records Clerk is responsible for directing, planning, coordinating, and administering the facility’s medical records program.
RESPONSIBILITIES :
Ensures that medical records are complete, accurate, and conform and state boards of health standards
Reports any variations noted and new regulations or requirements, in accordance with standard medical records practices
Trains staff in coding, indexing, filing, preparing and displaying of information, transcription, medical terminology nomenclature and classification of diseases, and computer services including such related matters as hospital organization, goals, policies and practices, and medical records ethics, laws and regulations
Supervises and monitors the release of confidential information in accordance with rules and regulations
Compiles statistical information and registers pertaining to the medical records department, ancillary services, and other statistical information as assigned or requested
Supervises and coordinates the preparation of statistical information for medical staff, medical staff committees, accreditation agencies, state agencies, and the administration
Participates and represents the medical records department in various facility committees and medical staff committees as assigned
Performs administrative and clerical support tasks
Appears in court when subpoenaed to testify about the authentication of medical records
Abides by the state peer review statute
Monitors communicable diseases and reports to the state DOH through the infection control officer
Provides diagnosis codes to the fiscal services department on a timely basis to expedite filing of insurance claims for patient services rendered as required by hospital and external agencies
Assist in the Quality Assurance and Performance Improvement (QAPI) process
other duties as assigned
QUALIFICATIONS :
EDUCATION / EXPERIENCE :
Two years medical records experience in a physician's office or other health care facility
Thorough knowledge of accepted medical-records practices including medical records ethics, classification, and nomenclature
Knowledge of accreditation standards and state health regulations
Ability to interpret medical records department policies and procedures and to apply them in specific situations
Thorough knowledge of federal and state regulations, laws, and utilization review committee planning, organization, and management
Knowledge of medical staff bylaws, rules, and regulations, and the state peer review statute
High school graduate or equivalent
ART (accredited records technician) or RRA (registered records administrator) designation preferred
OVERVIEW :
The social worker assistant will work closely with the Director of Social Services and with residents in the nursing home by identifying their psychosocial, mental and emotional needs along with providing, developing, and / or aiding in the access of services to meet those needs.
The nursing home social worker is responsible for fostering a climate, policies and routines that enable residents to maximize their individuality, independence and dignity. This climate shall provide residents with the highest practical level of physical, mental and psychosocial well-being and quality of life.
RESPONSIBILITIES :
Review facility policies and procedures as part of the facility’s interdisciplinary team to assure compliance with state and federal regulations
Participate in reviewing and setting policies concerning resident care and quality of life
Participate in developing facility social work policies
Develop, maintain and utilize a listing of current community resources that are useful to residents and their families / significant others
Participate in quality assurance interdisciplinary team meetings
Understand and meet all government requirements for social service documentation
Document progress in meeting the psychosocial needs of residents
Work with the interdisciplinary team and administration to promote and protect resident rights and the psychological well-being of each resident. Prevent and address resident abuse as mandated by law and professional licensure
Identify community changes and opportunities such as legislation, regulations and programs that affect nursing home residents
Work with residents, families, significant others and staff to provide support, information and organization for taking a more proactive role in self advocacy to improve the quality of life / care for individual residents and those who live and work within the nursing home and the community at large
Complete a social history and psychosocial assessment for each resident that identifies social, emotional, and psychological needs
Participate in the development of a written, interdisciplinary plan of care for each resident that identifies the psychosocial needs / issues of the resident, the goals to be accomplished for those needs / issues, and the appropriate social worker interventions
Ensure or provide therapeutic interventions to assist residents in coping with their transition and adjustment to a long-term care facility, including their social, emotional, and psychological needs
Ensure or provide support and education to residents / family members / significant others to assist in their understanding of placement and facility issues in addition to referring them to the appropriate social service agencies when the facility does not provide the needed services.
Provide groups for residents / family members / significant others as appropriate to their needs
Provide clinical interventions to address catastrophic events that occur during the resident’s stay in the facility
Coordinate the resident discharge planning process and make referrals for appropriate home care services prior to the resident’s return to the community
Educate staff regarding the role of the social worker in the facility and the psychosocial needs of the residents and their families / significant others including the problems of aging and disability.
Educate staff regarding cultural diversity and each staff member’s importance when caring for residents. Educate staff regarding residents’ rights and how to recognize and prevent abuse, neglect and mistreatment
Educate residents and families / significant others regarding their rights and responsibilities, effective problem solving and the extent of community, health and social services that are available to them, including those necessary for effective discharge planning.
Maintain log of facility grievances
Supervise facility grievances to ensure they are accounted for and resolved within 7 days.
QUALIFICATIONS :
EDUCATION / EXPERIENCE :
LSW, LCSW, or LICSW in the state employed
Prior work with elders in a community or long-term care setting is preferred
The nursing home social worker must have skills in communication, assessment and social work methods and techniques.
Must have a working understanding of social systems along with the ability to implement pertinent state and federal regulations.
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