Resident Health Information Services Coordinator

NewCourtland•Philadelphia, PA

7h•Onsite

About The Position

This role is responsible for ensuring the completeness, accuracy, and accessibility of resident clinical records. The coordinator develops and implements policies and procedures for medical records, including storage, retrieval, and safeguarding against unauthorized access. They conduct record reviews to ensure compliance with documentation policies, manage facility-approved abbreviations, and provide access to resident records upon request. The position also involves advising on the control, use, and release of clinical information, collecting clinical data, and communicating daily with the Nursing Home Administrator regarding medical records issues. Additionally, the coordinator is involved in hiring and managing medical records staff, participating in the long-term care survey process, and maintaining electronic medical records. Knowledge of long-term care insurances, medical assistance processes, daily census, and quality assurance audits is required.

Requirements

Sufficient information to identify residents
Record of residents' assessments
Plan of care and services provided
Results of any pre-admission screenings
Compliance with medical record documentation policies
Appropriate safeguards against unauthorized access and use of computer-based medical records
Procedures to maintain confidentiality of all information contained in residents' records
Obtain authorized consents to release information
Releasing information without written consent of resident or legal representative only when required by law
Knowledge regarding all long-term care insurances and medical assistance processes and facility practices
Knowledge of daily census communication and how it pertains to the medical record and billing practices
Maintains current skills and knowledge through continuing education
Applies information to job responsibilities
Maintains survey Department of Health Entrance Manual
Maintains the credentials for licensed Physicians and Consultants

Nice To Haves

Participates in Triple Check for Medicare.
Assists and supports the Admissions department as needed.

Responsibilities

Ensures all 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 to ensure medical records are complete, accurate, accessible, and organized.
Develops and implements record storage and retrieval systems that comply with applicable record retention laws and maintains accessibility of records.
Inspects closed records for completeness, systematically organizes them for long-term storage, and reports delays in completion to the Nursing Home Administrator.
Develops and maintains appropriate 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 facility-approved 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 of clinical record information, ensuring confidentiality and obtaining authorized consents for release of information.
Advises Administration, physicians, and staff on requirements regarding the control, use, and release of clinical information.
Advises Administration on ways to safeguard the confidentiality of medical records for facility staff.
Collects and displays clinical data as requested by Administration, committees, regulatory agencies, or accrediting bodies.
Communicates daily with the Nursing Home Administrator to discuss 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 during surveys, and directing information collection.
Collaborates with Administration to develop responses to survey reports and maintains current skills through continuing education.
Actively participates in the planning and implementation of electronic medical records.
Maintains the Department of Health Entrance Manual.
Maintains knowledge regarding long-term care insurances, medical assistance processes, and facility practices.
Maintains knowledge of 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 the 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.