Medical Records Coordinator

PruittHealth•Franklin, GA

13d

About The Position

The Medical Records Coordinator is responsible for recordkeeping procedures and storage of clinical records in accordance with facility policies and procedures, professional standards, and state and federal long-term-care regulations. The role establishes and implements policies and systems to ensure records are complete, accurately documented, readily accessible, systematically organized, and appropriately protected. The coordinator collaborates with the Nursing Home Administrator on department resources, staffing, and budget matters, and supports regulatory surveys and ongoing quality improvement.

Requirements

High school diploma or equivalent.
At least one year of experience as a medical records practitioner in a long-term-care facility.
Participate in required surveys and reports, continuing education, and mandatory in-services.
Follow applicable confidentiality, compliance, resident-rights, and safety requirements.

Nice To Haves

Current certification as an Accredited Records Technician is preferred.
Certification as a Registered Records Administrator is preferred.

Responsibilities

Ensure clinical records include resident identification, assessments, care plans and services, state-conducted preadmission results, and progress notes.
Develop and participate in implementing facility policies and procedures for complete, accurate, accessible, and organized medical records.
Develop and implement record storage and retrieval systems that meet retention requirements and maintain record accessibility.
Inspect closed records for completeness, organize them for long-term storage, and report completion delays to the Nursing Home Administrator.
Safeguard computer-based medical records from unauthorized access and use.
Evaluate medical records and record formats, recommending changes to improve record quality and recordkeeping practices.
Review open and closed records for compliance with documentation policies and report findings to the Nursing Home Administrator and Director of Health Services.
Develop and deliver staff education on documentation policies and practices, confidentiality, and compliant information release.
Maintain, update, and distribute approved facility abbreviations and definitions.
Provide residents or legal representatives access to records, including current medical records, within 24 hours of request and copies within two working days.
Safeguard clinical records against loss, destruction, and unauthorized access or use; protect confidentiality, obtain authorized release consents, and release information without written consent only when required by law.
Advise administration, physicians, and facility staff on requirements for controlling, using, and releasing clinical information; advise administration on protecting facility staff medical-record confidentiality.
Conduct quality-control assessments of staff implementation of medical-record policies and procedures, analyze findings, and implement performance improvements.
Collect and display clinical data requested by administration, facility committees, regulatory agencies, or accrediting bodies.
Participate in department budget development and provide the Nursing Home Administrator with financial information about department needs and status.
Communicate daily with the Nursing Home Administrator about medical-record and budget issues, and recommend staffing levels and types needed to meet facility needs and legal requirements.
Participate in long-term-care surveys by instructing staff on conduct and disclosure, remaining available while surveyors are onsite, and directing timely collection of requested information.
Address identified problems and take corrective action during surveys when appropriate; gather and present supplemental documentation and collaborate on responses to survey reports.
Maintain skills and knowledge through continuing education, apply learning to job responsibilities, and perform other duties assigned by the supervisor.
Participate in center or agency licensure/JCAHO surveys and subsequent required reports.
Attend continuing education programs and mandatory in-services.
Respect residents' rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to raise complaints.
Comply with the corporate compliance program.
Report job-related occupational hazards, including potential exposure to blood and body fluids.
Follow safety regulations and procedures, including fire protection and prevention, smoking regulations, infection control, and safe equipment use.