Medical Records Personnel - Skilled Nursing

Senior Lifestyle•Auburn, ME

7d•$23•Onsite

About The Position

This position is responsible for maintaining the medical records systems to meet or exceed service standards as well as assist with general and clerical duties for the nursing department. The role requires maintaining complete and accurate medical records in compliance with regulatory agencies and the standards of excellence promoted by the American Medical Records Association. Responsibilities include managing the Admittance Log Book, assembling and completing new resident charts, and maintaining resident charts according to the Medical Records Procedure Manual. The role also involves establishing and maintaining a filing system, following procedures for releasing resident information, handling discharged residents' charts, and entering information in the “Death Registry”. Additionally, the position involves maintaining an inventory list of supplies, conducting daily inventory counts, verifying delivered supplies, maintaining nursing supplies, and reviewing/coding resident charges daily.

Requirements

High school diploma or general education degree (GED).
At least one year of experience in a health care facility.
Knowledge of medical terminology, helpful.
Acceptable fluency in English in order to perform job duties and speak, read, write, and communicate with supervisors, coworkers, residents, and applicable third parties.
Basic Clerical and computer skills including typing, data entry, filing, etc.
Ability to effectively communicate with residents, families, and all levels of staff.
Dedicated, compassionate, and energetic personal attributes.

Nice To Haves

Knowledge of medical terminology.

Responsibilities

Maintain complete and accurate medical records in compliance with the rules and regulations of all regulatory agencies and the standards of excellence promoted by the American Medical Records Association.
Maintain and keep current the Admittance Log Book.
Assemble and complete all new charts with resident assigned medical records number, name, physical name, or any other information pertinent to the resident.
Maintain resident charts according to Medical Records Procedure Manual to meet regulations and to ensure ease of handling, and reports deficiencies to Director of Nursing / Assistant Director of Nursing.
Establish and maintain a chart alphabetical filing system for both current and discharged residents in the medical records office.
Follow procedures established in Medical Records Procedure Manual for releasing resident information.
Handle discharged residents’ charts as outlined in medical Records Procedures Manual; monitor for uncompleted records or notes; notify Director of Nursing, or appropriate department head, of any deficiencies.
Enter all necessary information in the “Death Registry” when a resident expires. Obtain a copy of the death certificate and file with the residents’ chart.
Maintain master inventory list at par levels and current costs, updating as needed; monitor par levels with Nursing Unit Usage.
Conduct daily inventory count of all supplies storage areas.
Upon arrival of delivery of supplies, making sure quantities received, match packing slip.
Maintain nursing supplies, place delivered supplies in appropriate storage area, and apply charge tickets.
Review and code as needed all residents charges daily. Forward charges to Business Office.
Keep all supply storage areas neat and orderly.