Medical Records Coordinator

The Moorings Park Institute Incorporated•East Naples, FL

58d•Onsite

About The Position

The Medical Records Coordinator is responsible for performing the clerical duties of the Medical and Nursing Departments to assure that documentation for all medical record information is in compliance with established facility policies and procedures, and State and Federal regulations. Contributions: Health Information Management Functions: Maintains the security of health information systems and medical records. Assures physical protection is in place to prevent loss, destruction and unauthorized use of both manual and electronic records. Assures systems are in place to maintain confidentiality of manual health information. Manages the release of information functions for the facility including review and processing of all requests for information. Maintain facility policies and standards of practice to assure release of information requests are appropriate and meet legal standards and is processed in accordance with facility policies and procedures. Maintains a forms management system for development, review, and reproduction of facility forms. Maintain a master forms manual. Maintains systems for filing, retention and destruction of overflow records and discharge records in accordance with facility policy and relevant regulations. Participates in meetings and committees such as Medicare review, HIPPA policy and procedure committee. Assures systems are in place to maintain up to date resident-specific information in the computerized clinical information system and completes data entry functions as applicable. Orders and maintains a proper inventory of all medical record forms and distributes to appropriate staff. Maintains a current Medical Record Policy and Procedure book, including consultant reports. Records Management Functions: Completes and files the appropriate information in the master patient index information. Initiates the Chateau resident medical record and in house overflow file for thinned charts, prepare labels, etc. Completes admission checklists and admission audits. Completes coding and indexing of admission diagnoses. Conduct concurrent audits/quality monitoring at regular scheduled intervals. Code diagnoses at regular scheduled intervals. Thin in-house records in accordance with the written policy and procedure and file in chart order for discharge in the inhouse overflow file. Contact physicians or departments as needed when signatures or information is needed before records can be completed. Maintain a monitoring system to assure telephone orders and other information is signed or completed by the physician as needed. Maintain Medicare "Certification/Recertification" forms and follow-up with physicians for signature. Update discharge information on master patient index (manual or electronic). Record appropriate discharge information in the census register. Initiate the discharge record control log to monitor discharge record processing status. Obtain the discharge clinical record from the nursing station within 36 hours of discharge or death of a resident. Assemble record from the nursing station and the overflow file in established discharge order Analyze the record for deficiencies using the discharge record audit/checklist. Follow up and monitor discharge record deficiencies including monitoring/mail information to the physician for completion as applicable. Maintain discharge record control log. File discharge record in incomplete clinical record file until complete and then file the discharge record in the complete file. Code and index final diagnoses using the ICD-9-CM code books. Retrieves medical records promptly upon request. Destroys old medical records per policy in association with Director of Nursing and/or Administrator.

Requirements

High School graduate.
Long term care or healthcare experience preferably as a Coordinator of Health Information in another facility.
Knowledge of medical terminology.
Experience with ICD-9-CM coding.

Nice To Haves

Medical Records Technician certification desirable but not mandatory.
Training as a Medical Records Secretary or equivalent preferable, but not mandatory.

Responsibilities

Maintains the security of health information systems and medical records.
Assures systems are in place to maintain confidentiality of manual health information.
Manages the release of information functions for the facility including review and processing of all requests for information.
Maintains a forms management system for development, review, and reproduction of facility forms.
Maintains systems for filing, retention and destruction of overflow records and discharge records in accordance with facility policy and relevant regulations.
Participates in meetings and committees such as Medicare review, HIPPA policy and procedure committee.
Assures systems are in place to maintain up to date resident-specific information in the computerized clinical information system and completes data entry functions as applicable.
Orders and maintains a proper inventory of all medical record forms and distributes to appropriate staff.
Maintains a current Medical Record Policy and Procedure book, including consultant reports.
Completes and files the appropriate information in the master patient index information.
Initiates the Chateau resident medical record and in house overflow file for thinned charts, prepare labels, etc.
Completes admission checklists and admission audits.
Completes coding and indexing of admission diagnoses.
Conduct concurrent audits/quality monitoring at regular scheduled intervals.
Code diagnoses at regular scheduled intervals.
Thin in-house records in accordance with the written policy and procedure and file in chart order for discharge in the inhouse overflow file.
Contact physicians or departments as needed when signatures or information is needed before records can be completed.
Maintain a monitoring system to assure telephone orders and other information is signed or completed by the physician as needed.
Maintain Medicare "Certification/Recertification" forms and follow-up with physicians for signature.
Update discharge information on master patient index (manual or electronic).
Record appropriate discharge information in the census register.
Initiate the discharge record control log to monitor discharge record processing status.
Obtain the discharge clinical record from the nursing station within 36 hours of discharge or death of a resident.
Assemble record from the nursing station and the overflow file in established discharge order
Analyze the record for deficiencies using the discharge record audit/checklist.
Follow up and monitor discharge record deficiencies including monitoring/mail information to the physician for completion as applicable. Maintain discharge record control log. File discharge record in incomplete clinical record file until complete and then file the discharge record in the complete file.
Code and index final diagnoses using the ICD-9-CM code books.
Retrieves medical records promptly upon request.
Destroys old medical records per policy in association with Director of Nursing and/or Administrator.