Medical Records Specialist/LPN

Courtyards•Fulton, MS

10d•Onsite

About The Position

The Medical Records Specialist/LPN is responsible for compiling and maintaining resident medical records, entering data into software systems, and ensuring the completeness and accuracy of records in accordance with company policies and state regulations. This role involves collecting information from various sources, providing resident information to the business office, and potentially participating in MDS and UR meetings. The specialist will also process transfer/discharge records, maintain records of former residents, and assist in coordinating Nursing Department activities. Additionally, the role may involve running errands for documentation, auditing Medicare documentation, performing QI and IC functions, and resolving coding/diagnosis discrepancies. The specialist will also prepare statistical and narrative reports, maintain hard copy records for emergencies, compile data for agencies, and oversee the appropriate use and auditing of software. A key responsibility includes medical chart auditing for various services and acting as the HIPAA Privacy Officer for the facility.

Requirements

Must meet all local health regulations and pass post-employment physical exam if required.
Knowledge, skill, and/or ability required to perform each essential duty satisfactorily.

Responsibilities

Compile and set up residents’ medical records and enter data into software system.
Collect information from nursing staff, physicians, and other sources and update data in software and hard copy needed.
Monitor and audit records for completeness and accuracy in accordance with company policies and state regulations.
Provide resident information to the business office.
May participate in completion of MDS’s, UR meetings and any other related functions.
Process transfer or discharge record and discharge auditing.
Maintain appropriate records on former residents, storage per company policy.
Assist in coordinating Nursing Department activities to include administrative support and audits and education.
Run errands that may include travel to hospitals and doctor offices for documentation needing signatures.
Daily auditing of Medicare documentation in support of Nursing and Therapy RUG scores as well as changes in condition for all records.
QI and IC functions as time permits and as directed.
Nursing, physician services, and other clinical services and medical records audits.
Utilization Review Committee meeting member responsibilities.
Resolve/clarify codes and diagnoses with conflicting, missing or unclear information and consult with doctors or others to get information.
Prepare statistical reports or narrative reports for physician, facility, company, or state agency (vital records, death report, infection reporting).
Prepare hard copy of records for use during power failures and emergency situations as per policy.
Compile census, demographic or medical data as requested by facility, company, or state/federal agency.
Oversee appropriate use and documentation in software and provide audits/education as needed or directed.
Medical chart auditing in support of Medicare Part B services, clinical services such as QI and IC, chart audits for nursing and physician services.
HIPAA Privacy Officer responsible for the facility’s HIPAA compliance, in conjunction with the Administrator and HIM, including but not limited to all regulations, laws, policies and procedures, forms and logs.