Medical Records Technician
About The Position
We are hiring a Medical Records Technician. Someone who ensures accuracy and completeness of residents’ medical records. Contacts Director of Nursing, physicians, hospitals, clinics or doctors’ offices and coordinates with receipt of appropriate documents, including but not limited to authorization letters, Medicare certification records, and physician order sign offs to join our growing team. If you enjoy working with people in a fast-paced environment and are excited about the opportunity to make a difference every day, then this role may be for you! This is for the What You Will Do: Audits in-house medical records to adhere to established criteria; assures completeness, accuracy and internal consistency concurrently with admission, residency, transfer, and upon discharge. Verifies compliance with regulations and policies, including but not limited to admission charts, physicians’ visits, weekly nurse’s progress notes, medication administration records, treatment records, ADL records, daily, weekly and monthly weight records, monthly psychotropic progress notes, laboratory results, ancillary therapy records, interdisciplinary report documentation and any other qualitative discharge audits as assigned. Routinely reports all audit results to the Director of Nursing. Ascertains that the final diagnosis has been listed according to the selected nomenclature of the Health Center and accrediting agencies. Maintains the admission and disposition (discharge, deaths, and transfers) register and other systems involving resident information. Obtains all consent, releases, approvals and related data from insurances, residents and responsible parties regarding provisions of contract services to residents and/or release of medical records. Codes admitting diagnoses according to the chosen classification system. Completes statistical reports on the community’s operations for licensing, approving and accrediting agencies. Maintains in-house medical charts and an accurate and easily accessible filing system for Health Center records. Assembles and checks for missing/incomplete documents in medical records of discharged residents by clarifying or following up for complete records. Files discharged resident charts. Manages medical records within the Sequoia Living Electronic Health Record system to include reviewing information, identifying and correcting inaccurate information, notifying care providers of record deficiencies, tracking outstanding issues, resolving discrepancies by collecting and analyzing information. Submits monthly billing to accounting for ancillary charges. May provide backup for Medical Administrative Specialist and Unit Coordinator. Performs other work as assigned.
Requirements
- Basic knowledge of medical terminology.
- Advanced knowledge of Health Insurance Portability and Accountability Act (HIPAA).
- Working knowledge of long-term care regulations.
- Excellent English written and verbal communication skills.
- Organizational and analytical skills to plan and complete work assignments with minimal supervision and within established deadlines.
- High school graduate or equivalent.
- Minimum of three (3) years of medical records experience in a health care setting.
Nice To Haves
- Accredited Record Technicians (ART) certification preferred.
- Electronic Health Records (EHR) experience preferred.
- Experience in long term care is desirable.
Responsibilities
- Audits in-house medical records to adhere to established criteria; assures completeness, accuracy and internal consistency concurrently with admission, residency, transfer, and upon discharge.
- Verifies compliance with regulations and policies, including but not limited to admission charts, physicians’ visits, weekly nurse’s progress notes, medication administration records, treatment records, ADL records, daily, weekly and monthly weight records, monthly psychotropic progress notes, laboratory results, ancillary therapy records, interdisciplinary report documentation and any other qualitative discharge audits as assigned.
- Routinely reports all audit results to the Director of Nursing.
- Ascertains that the final diagnosis has been listed according to the selected nomenclature of the Health Center and accrediting agencies.
- Maintains the admission and disposition (discharge, deaths, and transfers) register and other systems involving resident information.
- Obtains all consent, releases, approvals and related data from insurances, residents and responsible parties regarding provisions of contract services to residents and/or release of medical records.
- Codes admitting diagnoses according to the chosen classification system.
- Completes statistical reports on the community’s operations for licensing, approving and accrediting agencies.
- Maintains in-house medical charts and an accurate and easily accessible filing system for Health Center records.
- Assembles and checks for missing/incomplete documents in medical records of discharged residents by clarifying or following up for complete records.
- Files discharged resident charts.
- Manages medical records within the Sequoia Living Electronic Health Record system to include reviewing information, identifying and correcting inaccurate information, notifying care providers of record deficiencies, tracking outstanding issues, resolving discrepancies by collecting and analyzing information.
- Submits monthly billing to accounting for ancillary charges.
- May provide backup for Medical Administrative Specialist and Unit Coordinator.
- Performs other work as assigned.
Benefits
- medical and dental coverage or pay a cash stipend if you are covered on another plan.
- Life Insurance
- Commuter Benefits
- Emergency Relief Fund
- Flexible Spending Account
- 18 PTO
- 8 Holidays
- 6 days per year available to provide pay when on an approved Leave of Absence and much more!
- Generous PTO and holidays
- Employee Referral Award
- Employee Recognition Programs
- Sign On Bonus.
- Sign on bonus of $3,000 if hired for a PT or FT CNA position.
- We offer on the job training and professional development opportunities.
- Scholarships too!
- We offer tuition and/or fee assistance for qualified programs.
- Covid protocols in place to keep everyone safe.
- Competitive wages and growth opportunities.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
