Medical Records

The Bayshore on Hilton Head•Mystic, CT

3h•$20 - $24•Onsite

About The Position

The Medical Records Secretary is responsible to work in accordance with established policies and procedures and/or specific instructions from the Director of Nursing. Is responsible for proper maintenance and storage of the Health Center medial records. Is responsible for the properly recording, filing and upkeep of the Health Center medical records. Responsible for Nursing Scheduling, assists with CNA scheduling when necessary.

Requirements

Must possess a High School diploma or GED
Knowledge of medical terminology preferred.
Experience in a health care setting, preferably in long term care.
Good judgement required
Ability to communicate effectively in English.

Responsibilities

Maintains complete and accurate medical records for current and discharged residents.
Maintains current charts with information pertinent to resident identification and provides manageable handling charts by removing, filling, and storing excess documentation in accordance with state and federal guidelines.
Prepares charts for admission and after discharges; monitors charts for incomplete data.
Provides appropriate, authoritative person with medical records and administration with statistical compilation of data as required.
Maintains and keeps current Census Book and Resident Index Cards and state required census.
Coordinates and maintains minutes to all necessary Quality Assurance meetings as required.
Serves as Health Center Receptionist, when necessary. Manages handling of Health Center mail when necessary.
Assists in ordering supplies, dealing with vendors and monitoring resident use of supplies for proper billing and completing inventory.
Updates and maintains Health Center forms, policies and procedures, Medicare denial letters and other information.
Assists Director of Nursing, Social Worker, and Administrator with special projects or assignments as needed.
Sends correspondence to providers relating to requested medical record information.
Maintains confidentiality of medical data.
Attends in-service training, educational seminars, and staff meetings as needed to stay abreast of current nursing changes and new policies as required by the department.
Acts as secretary to Director of Nursing on Health Center projects, assignments, policies and procedures and provides assistance to the Director of Nursing and Social Worker as necessary to facilitate the communication of information to and from families, responsible parties, staff, physicians, consultants, etc.