Medical Records LPN

Job Description

Job Description

Overview

Assist in maintaining residents’ medical records in accordance with facility policies and with state and federal regulations; Serve as the designated Compliance Liaison for the facility.

Responsibilities

• Meet the physical and sensory requirements stated below and be able to work in the environment described.
• Exhibit positive customer service both to internal and external customers.
• Identify and participate in process improvement initiatives that improve customer experience, enhance workflow, and/or improve the work environment.
• Other special projects and duties, as assigned.

Health Information Oversight

• Manage all aspects of medical records throughout its lifecycle, including admission through discharge, and retention in long-term storage where applicable. Ensure accuracy, timeliness, completeness, security, and regulatory compliance.
• Upload paper-based patient records to the electronic chart promptly upon receipt.
• Maintain organized auxiliary clinical and administrative records in compliance with company retention policy to support legal discovery, reporting, and internal reference.
• Manage long-term storage of paper documents by labeling and preparing files, and sending records to offsite storage, in accordance with retention schedules. Assist in locating information housed in long- term storage, and place orders to retrieve requested information as needed.
• Follow up with hospitals and external providers to obtain documentation after transfers or appointments, ensuring timely inclusion in the patient chart.
• Track and follow up on physician visits to ensure regulatory compliance; obtain missing visit notes from providers and escalate delays to facility management for resolution.
• Conduct routine audits to verify required documentation; present findings in daily morning meetings, follow up on deficiencies, and integrate results into QAPI reporting.
• Coordinate all record requests by forwarding to facility management within 24 hours of receipt and communicating with requestors as needed.
• Respond to approved medical record requests by retrieving and releasing records in accordance with company policy and confidentiality standards.
• Serve as a subject matter expert for staff and leadership on standards and regulations related to health information management.

Compliance Liaison Duties

• Act as Compliance Liaison for facility
• Assist, when requested, in the:
  - Annual Compliance risk assessment process by reminding stakeholders to complete the annual survey;
  - Completion of annual Compliance education by reminding stakeholders of the due date;
  - Periodic distribution of the code of conduct and compliance policies;
  - Monthly distribution of Compliance Newsletter and Compliance Tips to stakeholders;
  - Compliance investigations, by escalating allegations of violations of the Code of Conduct or policies to the compliance office;
• Function as a communication channel to and from the compliance office and assist compliance officer with addressing compliance questions.

Qualifications

• Associates degree or higher in Health Information Management, Healthcare Administration, or related field from an accredited college is required. Extensive experience in Health Information may be considered in lieu of a degree.
• Registered Health Information Technician or Administrator (RHIT or RHIA) credential is preferred.
• Minimum of two years (2) experience in a health care facility required; Skilled nursing facility or other long-term care setting with Health Information Management experience is preferred.
• Knowledge of legal, ethical, and professional practice standards as they apply to Health Information Management.
• Knowledge of medical terminology, anatomy and physiology, and regulatory requirements.
• Possess strong analytical, critical thinking, and problem-solving skills.
• Demonstrate intermediate to advanced skills in Microsoft Word, Excel, Power Point and Outlook; Experience with EMR and/or MatrixCare preferred.
• Highest level of professionalism and personal integrity with the ability to use independent judgement and maintain confidentiality.