Medical Records

PACS

1d•Hybrid

About The Position

The primary purpose of this job position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines, as well as the facility’s established privacy policies and procedures. This role involves managing administrative functions related to medical records, assisting with committee and personnel functions, participating in staff development, ensuring safety and sanitation, and managing equipment and supplies. The position requires the ability to handle sensitive information, maintain confidentiality, and work effectively within a healthcare environment.

Requirements

High school diploma or GED.
Ability to type a minimum of 45 words per minute.
Ability to use dictation equipment.
Knowledgeable in computers, data retrieval, input and output functions.
Must be able to read, write, speak, and understand the English language.
Ability to read technical procedures.
Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.
Ability to make independent decisions when circumstances warrant.
Ability to deal tactfully with personnel, residents, visitors, and the general public.
Ability to work harmoniously with other personnel.
Ability to minimize waste of supplies, misuse of equipment, etc.
Ability to seek out new methods and principles and be willing to incorporate them into existing practices.
Ability to follow written and oral instructions.
Must not pose a direct threat to the health or safety of other individuals in the workplace.
Must be able to move intermittently throughout the workday.
Must be able to speak and write the English language in an understandable manner.
Must be able to cope with the mental and emotional stress of the position.
Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately.
Must function independently, have personal integrity, have flexibility, and the ability to work effectively with other personnel.
Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination.
Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet.
Must be able to push, pull, move, and/or carry a minimum of 25 pounds a minimum distance of 50 feet.
May be necessary to assist in the evacuation of residents during emergency situations.

Nice To Haves

Working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required.
On-the-job training provided in medical record and health information system procedures.

Responsibilities

Receive and follow work schedule/instructions from supervisor.
Assist in organizing, planning, and directing the medical records department.
Assist the Medical Records/Health Information Consultant as required.
Maintain minutes of meetings and file as necessary.
Develop and maintain good working rapport with inter-department personnel and other departments.
Assist in recording all incidents/accidents and file accordingly.
Retrieve resident records (manually/electronically) and deliver as necessary.
File nurses’ notes, resident assessments, progress notes, laboratory reports, x-ray results, correspondence, etc., into resident charts.
Collect, assemble, check, and file resident charts as required.
Assist MDS Coordinator in scheduling assessments.
Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.
Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.
Establish a procedure to ensure resident charts/records do not leave the medical records room except as authorized.
Maintain a record of authorized information released from charts/records.
Abstract information from records for insurance companies, Medicare, Medicaid, VA, etc., in accordance with current Privacy Rules.
Index medical records as directed by the medical records/health information consultant.
Maintain various registries as directed, including registers for admission and discharge of residents.
Transcribe and type reports for physicians as necessary.
Collect charts, assemble them in proper order, and inspect them for completion.
Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas.
Batch resident information into the computer and retrieve resident demographic information.
Answer telephone inquiries concerning medical records functions and prepare written correspondence.
Retrieve medical records when requested by authorized personnel.
Assure that medical records taken from the department are signed out and signed in upon return.
File active and inactive records in accordance with established policies.
Agree not to disclose assigned user ID code and password and promptly report suspected or known violations.
Agree not to disclose resident’s protected health information and promptly report suspected or known violations.
Report any known or suspected unauthorized attempt to access facility’s information system.
Assume the administrative authority, responsibility, and accountability of performing assigned duties.
Perform secretarial duties for committees of the facility as directed.
Collect and assemble/compile records for committee review and prepare reports for staff/other committees.
Report known or suspected incidents of fraud.
Ensure departmental computer workstations left unattended are properly logged off or password protected.
Attend and participate in mandatory facility in-service training programs.
Attend and participate in workshops, seminars, etc., as approved.
Report all unsafe/hazardous conditions, defective equipment, etc., to supervisor immediately.
Report equipment malfunctions or breakdowns to supervisor.
Ensure supplies have been replenished in work areas.
Assure that work/assignment areas are clean and records, files, etc., are properly stored.
Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
Perform other duties as assigned.