What are the responsibilities and job description for the Medical Records position at Southwest LTC?
Job Details
Description
JOB SUMMARY:
The Medical Records Department participates in all activities related to the establishment, maintenance, and closing of resident medical records in accordance with facility policies and regulations.
EDUCATION:
High School diploma required. Medical Records certification preferred, but not required.
Must continue to maintain background checks in good standing according to the requirements of Texas Department of Aging & Disability Services (DADS).
Qualifications
QUALIFICATIONS:
- Must have computer skills and knowledge in filing, medical terminology, ICD-9 coding, and other clerical functions.
- Strong organizational skills and attention to detail.
- Considerable initiative and judgment is needed.
- Must be able to communicate in English, both verbally and in writing, and possess sufficient communication skills to perform the tasks required.
RESPONSIBILITIES:
- Sets up residents medical records; collects information from nursing staff, physicians and other sources, updates records, thins charts, and closes charts when necessary.
- Monitors and audits records for completeness and accuracy, and thins charts in accordance with facility policy and regulations.
- Processes transfer or discharge records and maintains appropriate records on former residents.
- Assists with all medical record requests from residents, family members, insurance companies, legal authorities, etc. according the company policy.
- May assist in the ordering, stocking, and maintaining inventory of nursing supplies.
- Ensures understanding of, and compliance with, all rules regarding residents rights and HIPAA regulations.
- Performs other duties as assigned by Supervisor.
PHYSICAL DEMANDS:
Use the percentages range as follows:
|
|
|
0% |
Never |
|
1 |
- |
33% |
Occasionally |
|
34 |
- |
66% |
Frequently |
|
67 |
- |
100% |
Continuous |
Requires full range of body motion including:
|
1. |
Standing/Walking: |
Frequently: |
Administrative filing; running off copies on copier; faxing copies; delivering/retrieving documents as necessary. |
|
2. |
Bending/Stooping: |
Frequently: |
Worker will be bending and stooping as he/she is filing documents, reloading copier and computer with paper. |
|
3. |
Lifting/Handling: |
Occasionally: |
Worker will be lifting and handling when restocking nursing supplies, filing resident records (active and inactive). Range of weight: 1-50 pounds. |
|
4. |
Carrying: |
Occasionally: |
Worker will carry documents and administrative/nursing supplies. Range of weight: 1-50 pounds |
|
5. |
Balancing: |
Occasionally: |
Moving supplies from one storage room to another, resident file folders from active to inactive. |
|
6. |
Pivoting/Turning: |
Occasionally: |
Stocking supplies and forms. Copying, handling records, file folders, etc. |
|
7. |
Crouching/Stooping: |
Occasionally: |
Storing resident files, folders, supplies; inventory for nursing department. |
|
8. |
Kneeling: |
Occasionally: |
Filing, stocking supplies. |
|
9. |
Reaching: |
Frequently: Frequently: Frequently: |
Filing administrative folders, records, etc. A. Greater than shoulder height B. Equal to Shoulder height C. Less than shoulder height |
|
10. |
Manual Dexterity: |
Continuously: |
Continuous data entry, copier, fax machine. |
|
11. |
Speaking/Hearing Seeing: |
Continuously: |
Answering phone, conversing with residents as well as employees and family members. |
JOB LOCATION: May work throughout all areas of the facility including the administrative office and nurses stations. May be exposed to communicable disease and/or bodily fluids, medical preparations, toxic substances and ionizing radiation.
