Medical Records

Carespring•West Chester, OH

1d•Onsite

About The Position

This position maintains the medical records in accordance with State and Federal regulations as well as professional standards of practice and facility policies and procedures to ensure complete, timely, and accurate medical records. This role is for a state-of-the-art, skilled nursing facility.

Requirements

Maintains or is willing to obtain Medical Records Certification
Detail oriented person and can complete tasks on a need based schedule
Knowledge of Microsoft Word, Excel highly encouraged.

Nice To Haves

PointClickCare experience is preferred.

Responsibilities

Performs routine audits of in-house charts upon admission and at least quarterly, to ensure completeness and accuracy.
Completes focus audits and PI audits on specific topics as directed by Administrator or Regional Medical Records Director.
Provides notification to the staff on deficiencies found in the record and does follow-up to ensure the in-house records are complete.
Assembles the medical records of discharged residents.
Analyzes discharged charts for completeness and follows up with staff and physicians to ensure discharged records are completed.
Processes requests for medical information as directed by the Administrator, Regional Medical Records Director and/or corporate Risk Manager (i.e., requests from residents, attorneys, for insurance reimbursement, in response to a subpoena).
Maintains Release of Information Log for all requests for medical records and copies released for payment, continuity of care, and health care operations.
Completes Accounting of Disclosures form according to HIPAA policies and files in resident’s chart.
Maintains the confidentiality of medical records by ensuring confidentiality of health information.
Monitors physician visits and reports non-compliance to the DON/Administrator at least monthly.
Purges charts, maintains destruction log, and maintains information for records at off-site storage facility.
Assigns ICD-9 CM codes for resident diagnoses.
Inputs diagnoses and codes in HCS system.
Coordinates physician dictation with outside transcription company.
Files any loose sheets needing to be attached to the record.
Maintains supply of forms in department and on nursing units.
Completes discharge/transfer notice when necessary for transfers to hospital or expired residents.
Inputs discharge/transfer data in HCS system and ECS.
Forwards requested records to Carespring Case Manager for managed care updates.
Serves as facility contact person to oversee Record Retention and Destruction Policy working with each department as documents/records are boxed for long term storage.
Sign-off on each Record Log to confirm proper completion.
Performs other duties as assigned.