Medical Records

Skilled Nursing Professionals•McAllen, TX

12h

About The Position

Grand Terrace Come join our team and start making a difference! The primary purpose of your job position is to assure that medical records are maintained in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program is maintained. ESSENTIAL DUTIES AND RESPONSIBILITIES : Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Responsibilities

All duties and responsibilities shall be performed as set forth in our established policies and procedures.
Adheres to and assures compliance with Code of Conduct, facility policies and procedures and all applicable rules, regulations and standards as promulgated by Federal, State, and accrediting agencies or regulating bodies. This includes, but is not limited to, Department of Health, Centers of Medicare and Medicaid Services, and other applicable regulatory agencies.
Assures that all staff complete required compliance training and processes.
Plan, develop, organize, implement, evaluate, and direct the medical records section in accordance with established policies and procedures. (Includes department policies and procedures, job descriptions, etc.)
Establish procedures to be followed in the collection, coding and indexing, and the filing/retrieving of medical records.
Advise the administrator on federal and state laws concerning medical records.
Review discharge and death records, as well as records on the nursing units.
Review department policies and procedures, at least annually, and participate in making recommended changes.
Collect, assemble, check, and file resident charts and personnel records as may be necessary.
Ensure that incomplete records/charts are returned to nursing service for correction.
Develop procedures to ensure records are properly assembled, coded, signed, indexed, etc., before filing.
Ensure established policies and procedures for the medical records section are followed by all personnel.
Establish procedures to ensure that charts/records are not taken from the section except as authorized. Periodically check such records to assure this policy is being followed.
Abstract information from records as authorized/required for insurance companies, Medicare, etc.
Ensure that registries are properly maintained for admission and discharge of residents.
Prepare medical records for court trials as required.
Develop and implement our written medical records policies and procedures.
Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed. Attend such meetings as may be necessary or appropriate.
Serve on various committees of the facility as appointed by the administrator.
Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility to assure that medical records can be properly maintained and problem areas can be identified and corrected.