Medical Records Coordinator

PruittHealth • Augusta, GA

4d • Onsite

About The Position

The Medical Records Coordinator assumes responsibility for record-keeping procedures and the storage of all clinical records in a manner consistent with facility policies, professional standards, and state and federal laws and regulations for long-term care facilities. This role establishes and implements policies to ensure that records are complete, accurately documented, readily accessible, and systematically organized. The coordinator collaborates with Nursing Home Administrators to allocate department resources efficiently and economically to achieve department objectives.

Requirements

• High school diploma or equivalent.
• A minimum of 1 year of experience as a medical records practitioner in a long-term care facility.

Nice To Haves

• Current certification as an Accredited Records Technician.
• Certification as Registered Records Administrator.

Responsibilities

• Ensures all clinical records contain sufficient information to identify the resident, a record of assessments, the plan of care and services provided, results of any preadmission conducted by the State, and progress notes.
• Initiates and participates in the development of facility policies and procedures to ensure medical records are complete, accurately documented, readily accessible, and systematically organized.
• Develops and implements a record storage and retrieval system that complies with applicable record retention laws and maintains accessibility of records.
• Inspects closed records for completeness and systematically organizes them for long-term storage, reporting delays to the Nursing Home Administrator.
• Develops and maintains appropriate safeguards against unauthorized access and use of computer-based medical records.
• Evaluates medical records for format and makes recommendations for continuous improvement of facility records and record-keeping practices.
• Evaluates compliance with medical record documentation policies through reviews of open and closed records, reporting findings to the Nursing Home Administrator and Director of Health Services.
• Develops and conducts educational programs for facility staff on documentation policies and practices, providing training to ensure staff can distinguish between confidential/non-confidential information and release information only in compliance with facility policies.
• Maintains, updates, and distributes lists of facility-approved abbreviations and definitions.
• Provides access to all resident-related records within 24 hours of request and makes copies available within 2 working days.
• Develops and implements safeguards against loss, destruction, unauthorized access, or use of clinical record information, including procedures to maintain confidentiality and obtain authorized consents for release of information.
• Advises Administration, physicians, and facility staff on applicable requirements regarding the control, use, and release of clinical information, and on ways to safeguard the confidentiality of facility staff medical records.
• Conducts periodic quality control assessments of staff implementation of medical records policies and procedures, analyzing findings and developing improvements.
• Collects and displays clinical data requested by Administrations, facility committees, regulatory agencies, or accrediting bodies.
• Participates in the development of the department budget and provides relevant financial information to the Nursing Home Administrator.
• Communicates with the Nursing Home Administrator daily to discuss medical record and budget issues, and recommends personnel needs to meet facility requirements.
• Actively participates in the long-term care survey process by instructing staff, being present when surveyors are on-site, and directing the collection of information.
• Demonstrates concern for identified problems and undertakes corrective action during surveys if appropriate, gathering and presenting supplemental documentation, and collaborating on responses to survey reports.
• Maintains current skills and knowledge through continuing education and performs other duties as assigned by supervisor.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED