What are the responsibilities and job description for the Medical Records Coordinator position at The Williamsport Home?
Job Details
Description
POSITION SUMMARY:
Assures that open and closed resident medical records are maintained in compliance with Federal and State guidelines, as well as, facility policies and procedures. Assures completeness of records.
DELEGATION of AUTHORITY:
The Medical Records Coordinator is delegated the administrative authority, responsibility, and accountability necessary to carry out duties assigned.
ESSENTIAL FUNCTIONS;
General: 70%
1. Develops and implements facility’s written medical records policies and procedures. Reviews and updates policies and procedures on an annual or as needed basis, with consultant as needed.
2. Assists in planning, developing, organizing, implementing, evaluating, and directing the Medical Records Department in accordance with established standards and regulations.
3. Assures established policies and procedures for the Medical Records Department are followed by all personnel; evaluates and/or disciplines for same.
4. Upon a resident’s death/discharge, collects, assembles, checks and files resident’s medical record.
5. Ensures that incomplete records/charts are corrected, as is possible, and returned.
6. Establishes procedures to ensure charts/records are not removed from their designated
area without authorization. Establish a system to monitor for compliance.
7. Assures resident logs are maintained for resident admissions, discharges, and any hospitalization.
8. Reviews charts for updated physicals; flags same as necessary.
9. Reviews charts for timeliness of physician visits; notifies doctors of due visit dates as
necessary.
10. Abstracts information as authorized/required for Medicare, insurance companies, etc.
11. Attends Department Manager and other facility meetings as assigned.
12. Collects and assembles records for QA Committee review; prepares reports as assigned.
13. As necessary, assists in training related to medical records for all personnel according to
facility guidelines.
14. Confers with the Executive Director regarding relevant laws and issues.
15. Works with Medical Records Consultant.
16. Prepares medical records for court proceedings.
17. Helps with nursing unit coverage in the event of an emergency.
18. Provides annual capital and budget recommendations.
19. Purges (thins) current (active) charts and retains, in the Medical Records Department, the
purged records in chronological order, according to category of record.
Administrative: (20%)
20. Maintains a qualitative and quantitative audit/quality monitoring system. Collect and report data from audit findings to QA committee. Reports, monitors and follow-ups on problems and concerns found in QA audits to QA committee and related departments.
21. Periodically, meets with Executive Director and/or Associate Director to review departments, programs, problems, and progress on delegated projects.
22. Types list, letters, and reports as necessary
23. Yearly, coordinates and assists with closed records destruction after the TEN (10) year
Detention period has expired
Miscellaneous/other (10%)
24. Performs other work-related duties as assigned.
25. Maintains a safe work environment and exhibits safe work practices, assuring resident safety.
PHYSICAL DEMANDS:
Frequent sitting and moderate to frequent use of arms, hands and fingers.
Moderate standing, walking, bending and forward reaching.
Moderate to light carrying.
Requires lifting of light weight items (charts and files) up to 50 pounds.
Light twisting, stretching, and climbing.
Must be able to safely navigate steps carrying medical records up and down steps multiple times during the work day.
ENVIRONMENTAL CONDITIONS:
Occasional wet floor.
Hard floor surfaces.
Occasional dust, fumes, and noise.
Exposure to some hazardous materials
Qualifications
EDUCATION, EXPERIENCE and SKILLS REQUIRED:
1. High school graduate or equivalent.
2. Experience working with medical records and knowledge of medical terminology.
3. Strong verbal and interpersonal skills and interest/background in the technical/scientific field.
4. Ability to read, write, type and understand English.
5. Ability to use computers.
6. Ability to organize and establish systematic method for even flow of work.
7. Ability to work with minimal supervision and within a team
8. Training as a Medical Records Secretary or Equivalent
9. Knowledge of ICD-9-CM coding
10. Knowledge with documentation and legal issues
