Medical Records

Meadowbrook at Bloomer•Bloomer, WI

20h•Onsite

About The Position

The primary purpose of this role is to maintain resident medical records and health information systems in accordance with current federal and state guidelines, as well as the facility’s established privacy policies and procedures. The Medical Records/Health Information Clerk is delegated the administrative authority, responsibility, and accountability necessary for carrying out assigned duties. While efforts have been made to identify essential functions, this role may involve duties beyond those explicitly listed if they are similar, related, or essential to the position.

Requirements

Maintain resident medical records and health information systems in accordance with current federal and state guidelines.
Follow established privacy policies and procedures.
Follow work schedule/instructions from supervisor.
Maintain minutes of meetings.
File as necessary.
Develop and maintain a good working rapport with inter-department personnel.
Assist in recording all incidents/accidents.
File in accordance with established policies and procedures.
Retrieve resident records (manually/electronically).
Deliver as necessary.
Collect, assemble, check and file resident charts as required.
Files information such as nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.
Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.
Establish a procedure to ensure resident charts/records do not leave the medical records room except as authorized.
Maintain a record of authorized information released from charts/records.
Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc., in accordance with current Privacy Rules.
Index medical records as directed.
Maintain various registries as directed including register for admission and discharge of residents.
Transcribe and type reports for physicians as necessary.
Collect charts, assemble them in proper order, and inspect them for completion.
Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas as necessary.
Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.
Answer telephone inquiries concerning medical records functions.
Prepare written correspondence as necessary.
Retrieve medical records when requested by authorized personnel.
Assure that medical records taken from the department are signed out and signed in upon return to the department.
File active and inactive records in accordance with established policies.
Index medical records as directed.
Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations.
Agree not to disclose resident’s protected health information and promptly report suspected or known violations.
Report any known or suspected unauthorized attempt to access facility’s information system.
Assume the administrative authority, responsibility, and accountability of performing the assigned duties.
Perform secretarial duties for committees of the facility as directed.
Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.
Report known or suspected incidents of fraud to the Administrator.
Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen-saver activates within established facility policy guidelines.
Attend and participate in mandatory facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, etc.).
Attend and participate in workshops, seminars, etc., as approved.
Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately.
Report equipment malfunctions or breakdowns to your supervisor as soon as possible.
Ensure supplies have been replenished in work areas as necessary.
Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of workday, etc.
Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
Maintain the confidentiality of all resident care information including protected health information.
Report known or suspected incidents of unauthorized disclosure of such information.
Knock before entering a resident’s room.
Assure that residents’ rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are followed.

Nice To Haves

Assist the Medical Records/Health Information Consultant as required.
Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.
Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.
Perform secretarial duties for committees of the facility as directed.
Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.

Responsibilities

Maintain resident medical records and health information systems.
Receive and follow work schedule/instructions from supervisor.
Assist in organizing, planning, and directing the medical records department.
Assist the Medical Records/Health Information Consultant as required.
Maintain minutes of meetings.
File documents as necessary.
Develop and maintain good working rapport with inter-department personnel.
Assist in recording all incidents/accidents and file them.
Retrieve resident records (manually/electronically) and deliver as necessary.
Collect, assemble, check, and file resident charts.
File nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.
Assist MDS Coordinator in scheduling assessments.
Ensure incomplete records/charts are returned for correction.
Assist in developing procedures for proper completion, assembly, coding, and signing of resident records.
Establish procedures to ensure resident charts/records do not leave the medical records room except as authorized.
Maintain a record of authorized information released from charts/records.
Abstract information from records for insurance companies, Medicare, Medicaid, VA, etc., in accordance with current Privacy Rules.
Index medical records as directed.
Maintain various registries, including admission and discharge of residents.
Transcribe and type reports for physicians.
Collect charts, assemble them in proper order, and inspect for completion.
Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas.
Batch resident information into the computer and retrieve demographic information.
Answer telephone inquiries concerning medical records functions.
Prepare written correspondence.
Retrieve medical records when requested by authorized personnel.
Assure that medical records taken from the department are signed out and signed in upon return.
File active and inactive records.
Agree not to disclose assigned user ID code and password and report violations.
Agree not to disclose resident’s protected health information and report violations.
Report any suspected unauthorized attempt to access facility’s information system.
Perform secretarial duties for facility committees.
Collect and assemble/compile records for committee review and prepare reports.
Report known or suspected incidents of fraud.
Ensure departmental computer workstations are properly logged off or password protected.
Attend and participate in mandatory facility in-service training programs.
Attend and participate in approved workshops, seminars, etc.
Report all unsafe/hazardous conditions and defective equipment.
Report equipment malfunctions or breakdowns.
Ensure supplies are replenished in work areas.
Assure work/assignment areas are clean and records/files are properly stored.
Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
Maintain the confidentiality of all resident care information.
Knock before entering a resident’s room.
Assure residents’ rights are followed.