Admissions/Medical Records Nurse

Job Description

Job Description

Description:

Department: Nursing Administration

Reports To: Director of Nursing

Position Summary

The Admissions/Medical Records Nurse is responsible for managing resident medical records in accordance with facility policies, accepted health information management practices, and all applicable federal, state, and local regulations. This position ensures resident medical records are complete, accurate, confidential, readily accessible, and systematically organized.

Accountability: Director of Nursing

Medical Records Responsibilities

• Assemble and prepare admission medical records to ensure all required documentation is completed and organized upon resident admission.
• Perform routine audits of resident medical records to verify completeness, accuracy, regulatory compliance, and internal consistency.
• Audit discharged resident medical records for completeness, accuracy, required signatures, and proper filing order in accordance with facility policy and regulatory requirements.
• Perform medical record coding and maintain an accurate diagnosis list for each resident medical record.
• Participate in Case Mix audits and provide assistance with clinical documentation and record review as needed.
• Maintain an adequate inventory of all medical record forms and ensure current versions are readily available.
• Maintain resident medical records in accordance with HIPAA, CMS regulations, facility policy, and accepted standards for confidentiality, retention, storage, and release of information.
• Ensure medical records are organized, complete, readily accessible to authorized personnel, and maintained in a systematic manner.
• Answer incoming telephone calls courteously, direct calls appropriately, take accurate messages, and relay information promptly.
• Perform or assist with monthly reviews of nursing incident and accident reports as requested.
• Provide administrative and clerical support to the Director of Nursing and nursing department as assigned.
• Assist with clinical and administrative projects that support nursing operations and regulatory compliance.
• Demonstrate knowledge of and comply with facility policies regarding fire safety, emergency preparedness, sanitation, infection prevention, bloodborne pathogens, Hazard Communication, OSHA standards, and workplace safety.
• Promote positive, professional relationships with residents, families, visitors, vendors, government surveyors, and fellow employees while maintaining a professional appearance and attitude.
• Recognize, prevent, and immediately report suspected abuse, neglect, exploitation, or mistreatment of residents in accordance with facility policies and applicable regulations.
• Promote and maintain a safe, clean, organized, and therapeutic environment that supports quality resident care.
• Attend required facility meetings, department meetings, in-service education, and continuing education programs.
• Serve as an active member of the interdisciplinary team by placing residents' safety, dignity, quality of life, and well-being as the highest priority.
• Perform all other duties and responsibilities as assigned by the Administrator, Director of Nursing, or designee.

PHYSICAL REQUIREMENTS:

• Hold/handle
• Lift
• Carry
• Reach – at and below shoulder height
• Push/pull
• Grasp and handle – pens, paperwork and small equipment
• Sit, stand and walk
• Twist, bend, stoop, kneel, and squat
• Fine hand motor coordination
• Ability to read and write legibly
• Ability to comprehend and follow instructions
• Strong organizational skills
• Ability to work independently and take Initiative.
• Availability for Holidays and Weekends when necessary.
• Previous experience in Long-Term Care or Healthcare setting is preferred.
• Friendly, team-oriented attitude.

COGNITIVE AND SENSORY REQUIREMENTS:

Talking: Communicating with residents, families, visitors and staff

Hearing: To communicate effectively on the telephone, Taking instructions from the Administrator, To respond appropriately to disaster instructions and pages

Sight: For performing job effectively and correctly

Smell: For accurate detection and maintenance of facility odors

LICENSURE REQUIREMENTS:

Must be a Licensed Practical Nurse (L.P.N.) currently licensed and in good standing with the Board of Nursing in the State in which the facility is located.

SUMMARY OF OCCUPATIONAL EXPOSURE:

Tasks and procedures performed by the employee involve risks classified by C.D.C. as 

Category III. (No contact with blood or other bodily fluids to which universal precautions apply, if regular duties are performed.)

OTHER CONSIDERATIONS AND REQUIREMENTS:

Must be able to tolerate a high pace as typical for a nursing facility. Must be able to take and give instructions well and enjoy working with the elderly. Although employee is required to sit for prolonged periods of time, he/she must also be able to tolerate prolonged standing and walking.

FULL TIME BENEFITS

Tuition Reimbursement

Paid Time Off

Health Insurance

Vision Insurance 

Dental Insurance

Life Insurance

Opportunities for Advancement