Medical Records Coordinator - Crescent Grove Memory and Personal Care and Grove Pointe Assisted Living
Reports To: Executive Director, Crescent Grove Memory and Personal Care and Executive Director, Grove Pointe Assisted Living
Status: Full-Time, Non-Exempt
Work Hours: Normal business hours M - F, and other hours as needed by the Executive Director to meet the business needs.
Work Attire: Refer to apparel policy
Supervisory Duties: No
Primary Purpose: The purpose of this position is to appropriately maintain medical records for each resident in accordance with recognized standards, federal, state and local requirements. Medical records will be kept in accordance with facility procedures and Director will report resident needs/concerns to administration.
Duties Include, but are not limited to:
- Follows established standards of nursing practices to implement facility policies and procedures related to maintaining medical records in accordance with local, state and federal requirements
- Aids in implementing procedures to protect medical record information from loss, defacing or destruction prior to end of retention period
- Files medical records promptly and accurately, scanning into electronic health record as appropriate
- Processes admission and discharge records timely and accurately
- Receives and files all diagnostic reports promptly and accurately
- Collects all hard copy medical records from communities and scans into electronic medical record
- Audits transfer/discharge information for accuracy and completeness
- Identifies late and incomplete documentation and reports to supervisor
- Identifies inaccurate documentation and reports to supervisor
- Assists with data entry, printing and processing of computer forms, as assigned
- Performs assigned QA audits monthly, reporting results to the QA Committee for review and recommendations
- Assists in development of Action Plans and/or Performance Improvement Plans for medical records audits not meeting compliance
- Retrieves medical records promptly upon request by authorized individuals
- Audits medical records as assigned
- Assists nursing and administrative staff as assigned
- Assists nursing with Level of Care audits as necessary
- Assists in gathering and sending health records as requested
- Assists in answering telephones and routing calls promptly and accurately
- Follows facility Residents' Rights policies and procedures at all times
- Participates in facility education programs
- Attends staff meetings, in-service classes and committee meetings as assigned
- Assumes responsibility for compliance with federal, state and local regulations regarding maintaining the medical record
- Responds to residents' call for assistance promptly when appropriate
- Maintains confidentiality of resident and facility information
- Consistently works cooperatively with residents, nursing staff, families, etc.
- Is responsible for safety of residents
- Observes all safety policies and procedures
- Comes to work in a clean, neat uniform and consistently present an appropriate professional appearance
- Comes to work as scheduled and consistently demonstrate dependability and punctuality
- Assumes accountability for data contained in Employee Handbook
- Demonstrates attitude of teamwork when interacting with co-workers, other departments and visitors
- Performs all duties assigned in an effective, cooperative, timely and professional manner
- Observes infection control procedures
- Performs other related duties as directed by supervisor
- Participates in implementation of programs to improve resident care related to Quality Assurance
NOTE: This is not to be considered as an exhaustive statement of duties, responsibilities or requirements and does not limit the assignment of additional duties for this position.
Masonic Homes Kentucky is an EEO Employer - M/F/Disability/Protected Veteran Status
Qualifications/Skills Needed:
- Must be at least 18 years of age
- Must have high school diploma or GED
- 3+ years of medical records experience in long-term care or assisted living preferred
- Must be detail-oriented and self-motivated with ability to manage own time
- Knowledge of medical terminology
- Working experience with MS Office and data entry
- Ability to problem solve, work on deadlines and follow written/oral instructions
- Maintain clean, orderly and safe working environment
Working Conditions/Physical and Sensory Requirements:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Physical Activities:
How much on-the-job time is spent in the following physical activities (amount of time)?
Activity
None
Under 1/3 to 1/3
2/3
Over 2/3
Stand
X
Walk
X
Sit
X
Use hands to finger, handle or feel
X
Reach with hands and arms
X
Climb or balance
X
Stoop or kneel, crouch or crawl
X
Talk or hear
X
Taste or smell
X
Special Vision Requirements
Check all that apply
No special vision requirements
X
Close vision (clear vision at 20 inches or less)
Distance vision (clear vision at 20 feet or more)
Color vision (ability to identify and distinguish colors)
Peripheral vision (ability to observe an area that can be seen up and down to the left and right while eyes are fixed on a given point)
Depth perception (three-dimensional vision, ability to judge distance and spatial relationships
Weight and Force:
How much weight must be lifted or force must be exerted in this position (amount of time)?
Weight/Force
None
Under 1/3 to 1/3
2/3
Over 2/3
Up to 10 pounds
X
Up to 25 pounds
X
Up to 50 pounds
X
Up to 100 pounds
X
More than 100 pounds
X