Resident Health Information Services Coordinator

NewCourtland•Philadelphia, PA

1d•Onsite

About The Position

The Resident Health Information Services Coordinator is responsible for ensuring the completeness, accuracy, and accessibility of resident clinical records. This role involves developing and implementing policies and procedures for medical record management, including storage, retrieval, and safeguarding of both paper and electronic records. The coordinator also plays a key role in ensuring compliance with all applicable laws and regulations regarding resident information, advising administration on confidentiality matters, and participating in quality assurance initiatives and regulatory surveys.

Requirements

Knowledge of medical record documentation requirements.
Ability to develop and implement policies and procedures.
Proficiency in record storage and retrieval systems.
Understanding of data privacy and confidentiality laws.
Skills in evaluating compliance and reporting findings.
Ability to manage and maintain lists of abbreviations.
Proficiency in handling record requests and making photocopies.
Knowledge of safeguards against loss, destruction, or unauthorized access.
Ability to advise administration and staff on information control and release.
Skills in collecting and displaying clinical data.
Strong communication skills for daily interaction with Nursing Home Administrator.
Ability to recommend staffing needs.
Experience in hiring, retaining, and evaluating staff.
Knowledge of long-term care survey processes.
Ability to maintain current skills and knowledge through continuing education.
Experience with electronic medical records.
Knowledge of Department of Health Entrance Manual.
Knowledge of long-term care insurances and medical assistance processes.
Understanding of daily census, medical records, and billing practices.
Ability to conduct daily rounds on nursing units.
Willingness to assist the Admissions department.
Ability to maintain daily census.
Skills in quality assurance audits and minute-taking.
Ability to participate in required meetings.
Experience with Triple Check for Medicare.
Ability to maintain credentials for licensed Physicians and Consultants.

Responsibilities

Ensures clinical records contain sufficient information to identify residents, including assessments, plans of care, services provided, pre-admission screenings, and progress notes.
Initiates and participates in the development of facility policies and procedures for complete, accurate, accessible, and organized medical records.
Develops and implements record storage and retrieval systems compliant with retention laws and maintains accessibility.
Inspects closed records for completeness, organizes them for long-term storage, and reports completion delays to the Nursing Home Administrator.
Develops and maintains safeguards against unauthorized access and use of computer-based medical records.
Evaluates compliance with medical documentation policies through record reviews and reports findings to relevant departments and administrators.
Maintains, updates, and distributes lists of approved facility abbreviations and definitions.
Provides access to resident records within 24 hours of request and makes photocopies available within five business days.
Develops and implements safeguards against loss, destruction, or unauthorized access/use of clinical information, ensuring confidentiality and obtaining authorized consents for release.
Advises Administration, physicians, and staff on requirements for control, use, and release of clinical information.
Advises Administration on safeguarding the confidentiality of facility staff medical records.
Collects and displays clinical data as requested by Administration, committees, regulatory agencies, or accrediting bodies.
Communicates daily with the Nursing Home Administrator regarding medical records issues and recommends staffing needs.
Hires and retains qualified Medical Records Consultants, conducts interviews, provides performance reviews, and ensures staff meet qualification and performance standards.
Actively participates in the long-term care survey process, instructing staff, maintaining presence, directing information collection, and collaborating on survey responses.
Maintains current skills and knowledge through continuing education and applies information to job responsibilities.
Actively participates in the planning, introduction, and ongoing work associated with maintaining electronic medical records.
Maintains the Department of Health Entrance Manual.
Possesses knowledge of long-term care insurances, medical assistance processes, and facility practices.
Understands daily census communication and its relation to medical records and billing practices.
Conducts daily rounds on all nursing floor units.
Assists and supports the Admissions department as needed.
Maintains daily census.
Maintains quality assurance audits and organizes and takes minutes for the monthly Quality Assurance and Performance Key Indicators meetings.
Participates in all required meetings.
Participates in Triple Check for Medicare.
Maintains the credentials for licensed Physicians and Consultants.