Medical Records

Position Description

This position is responsible for the operation of the medical records program of the Client State Veteran Home - Flagstaff. Works cooperatively with others to ensure that the facility is meeting federal, state and VA regulatory requirements. Plays a key role in ensuring that medical records are complete, accurately documented, readily accessible, systematically organized and maintained in a confidential manner. Supervises Medical Records Technicians. Learns, implements and monitors Client Management System (AMS) methods. Utilizes AMS concepts and tools for problem solving and continuous work/process improvements and efficiencies.

Qualifications:

• Conducts a variety of complex and routine audits. Monitors medical records for completeness and accuracy on a continuing basis. Tracks all audits for follow up and reports to Department Heads/Administrator.
• Conducts a variety of audits to satisfy federal and/or state mandates and as requested by ASVH Administration. Verifies Medicare 5 day assessment dates, MDS completion and documentation. Audits Medicare Certification periods. Verifies order of diagnosis listing in chart. Audits for long term care physician visits; verifies physician visitation in accordance with regulation. Analyzes data for quality assurance, risk management utilization management, etc. Provides information as needed by decision makers.
• Compiles medical care, diagnosis and census data for statistical reports. Supplies statistical information as needed by other ASVH departments. Serves as facility's statistician and official repository for statistical reports.
• Codes diseases, diagnoses, and treatments using standardized coding systems as approved by AMRA for long-term care facilities. Ensures that the medical treatment records are provided to and obtained from other facilities to ensure continuity of care for residents.
• Functions as the Custodian of Records for the ASVH - Flagstaff. Verifies that all releases of information take place in accordance with applicable laws, policies and procedures. Processes all subpoenas.
• Interprets rules and regulations in maintenance of medical records and monitoring the accuracy of other department documentation. Develops and implements policies and procedures to meet regulatory and service requirements.
• Attends and participates in various meetings. Serves as member of various regulatory required committees at the discretion of the Administrator. Conducts staff meetings. Participates in special projects as assigned. Performs the work of a Medical Records Tech as required.
• Assures that all Physicians credentialing files are complete. Monitors for ongoing compliance, works with Physicians and Procurement to acquire needed documentation such as but not limited to Medical License, Certification of Insurance, Active DEA number, OIG eligibility, TB Clearance, Current Contract, HIPAA Agreement, Application, Reference Letters, Peer Review, Acceptance Letter, Agreement not to Boycott Israel and Approval Letter.
• Supervises subordinate staff to ensure the goals and objectives of the work unit are met. Plans, organizes, assigns and reviews the work of staff. Creates work schedules. Trains staff. Reviews, evaluates and manages staff job performance through monthly 1:1 coaching sessions and annual performance appraisals. Addresses staff problems. 10. Actively involved in AMS processes such as Huddle Boards, Problem Solving, Job Breakdown Sheets, Success Tracking, and Standardized Work. Participates fully in the QAPI process, our Quality Assurance and Performance Improvement program mandate by CMS which incorporates AMS.
• Other duties as assigned as related to the position (typically 5% - 10%)
  
  

Skills Preferred -

Interpersonal skills - Verbal and written communication skills - Basic computer skills - Time management skills - Problem solving skills - Analytical skills - Supervisory skills - Skill in auditing medical records - Skill in interpreting multiple federal and state regulations and ensuring compliance Ability to simultaneously manage multiple projects and adapt to changing priorities - Ability to work cooperatively with professional and nonprofessional staff - Ability to train technical and clerical staff - Ability to speak and write clearly and effectively - Ability to compile statistics and prepare comprehensive reports

Experience Required -

A minimum of one-year supervisory experience in a health care setting - Experience in long-term care - (Required) the ability to obtain and retain a valid AZ DPS Fingerprint Clearance Card.

Experience Preferred

Knowledge of rules, regulations, policies, procedures of section and work unit - Knowledge of Veterans Administration, CMS and State regulatory standards - Knowledge of standard medical records practices, procedures and techniques - Knowledge of standard office management and procedures - Knowledge of medical and legal terminology - Knowledge of current ICD coding and indexing - Knowledge of Medicare/AHCCCS and other insurance - Knowledge of HIPAA rules and regulations - Knowledge of record retention and disposal - Knowledge of OS system - Knowledge of Personnel Rules

Education Required -

LMSW required - must have a Masters degree in social work and an active social work license issued by the Client Board of Behavioral Health Examiners upon placement into position.

Education Preferred

2 or 4 yr degree in healthcare management