Medical Records Manager

The primary purpose of the Medical Records Director is to create new medical records and retrieve existing medical records by gathering appropriate record folders and contents; assigning and recording new record numbers; verifying existing record numbers; inputting and recording locations to the computer; and delivering records.

EXPECTATIONS OF EMPLOYEE

• Observe all facility safety policies and procedures.
• Complies with state, federal, and all other applicable health care and safety standards
• Demonstrates awareness and understanding of the facility culture and the expectations it incurs.
• Demonstrates awareness of how the culture of the facility affects our service to the veterans we serve.
• Follows facility Residents' Rights policies.
• Protect the confidentiality of all resident information.
• Assists families and other visitors as needed.
• Attends/completes required in-services and other required meetings.
• Come to work in clean, neat attire and consistently present a professional appearance.
• Come to work as scheduled and consistently demonstrate dependability and punctuality.
• Assume accountability for data contained in the employees' handbook.
• Perform all duties assigned in an effective, timely, and professional manner.
• Cooperatively accept assigned duties.
• Perform other related duties as directed by his/her supervisor.

ESSENTIAL JOB FUNCTIONS include the following. Other duties may be assigned. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

• Assure that all medical record information is protected and kept confidential.
• Protect all medical record information from loss, defacing, or destruction before the retention period ends.
• File medical records accurately.
• Retrieve medical records promptly upon request by authorized individuals and agencies.
• Identify late and incomplete documentation and report to individuals responsible for completion.
• Identify inaccurate documentation and report to individuals responsible for accuracy and documentation.
• Implement the system for advising all disciplines of documentation to be completed or corrected.
• Mail forms to physicians for completion, to the extent permitted by regulations.
• Maintain an accurate resident census report and distribute to designated individuals.
• Maintain a discharge analysis and disease index as required.
• Complete all information in master resident index file.
• Answer correspondence regarding release of information from medical records.
• Ensure Medicare residents have timely certification/re-certification forms signed by the attending physician.
• Implement policies and procedures to maintain the medical record system in compliance with federal, state, and local requirements.
• Computerize medical record data as required.

EDUCATION and EXPERIENCE : An equivalent combination of education, training, and experience will be considered.

• High School diploma or equivalent preferred; five or more years' experience as a Medical Records Manager in long-term care experience required; an equivalent combination of education and experience may be considered.

SUPERVISORY REQUIREMENTS of this position are generally as follows:

• This position does not have supervisory responsibility.

KNOWLEDGE, SKILLS and ABILITIES which may be representative but not all inclusive of those commonly associated with this position.

• Language Ability - Reads and interprets documents. Ability to write simple reports and correspondence. Written Communication - Writes clearly and informatively; able to read and interpret written information
• Verbal Communication - Talks to others to convey information effectively
• English Language - Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar
• Math Ability - Basic knowledge of arithmetic and algebra, and their applications
• Reasoning Ability - Ability to apply common sense understanding to carry out simple written or oral instructions
• Clerical - Knowledge of administrative and clerical procedures and systems such as word processing, managing files and records, stenography and transcription, designing forms, and other office procedures and terminology
• Quality Management - Demonstrates accuracy and thoroughness
• Organizational Support - Follows policies and procedures; completes tasks correctly and on time
• Adaptability - Adapts to changes in the work environment; changes approach or method to best fit the situation; Able to deal with frequent change, delays, or unexpected events
• Planning/Organizing - Prioritizes and plans work activities; advises for additional resources
• Attendance/Punctuality - Ensures work responsibilities are covered when absent; arrives at meetings and appointments on time
• Dependability - Completes tasks on time or notifies appropriate person with an alternate plan
• Professionalism - Treats others with respect and consideration regardless of their status or position; accepts responsibility for own actions

COMPUTER SKILLS/EQUIPMENT USED TO PERFORM THE JOB which may be representative but not all inclusive of those commonly associated with this position.

• Desktop/Notebook computers
• MS Office (Word, Excel, PowerPoint, etc.)

WORK ENVIRONMENT: environmental or atmospheric conditions commonly associated with the performance of the functions of this job.

• The employee may be exposed to blood, bodily fluids, odors, airborne particles, dust or fumes, and toxic or caustic chemicals
• The noise level in the work environment is usually moderate

PHYSICAL ABILITIES commonly associated with the performance of the functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is frequently required to talk or hear, stand, walk, sit, stoop, kneel or crouch, use hands to grasp, manipulate or feel objects, and reach with hands and arms. The employee is occasionally required to taste or smell.
• The employee must regularly lift and/or move up to 20 pounds and occasionally lift and/or move up to 50 pounds.
• Specific vision abilities required by this job include close vision, distance vision, color discrimination, peripheral vision, depth perception, and the ability to adjust focus.
• NOTICE: This position requires a criminal background check. Therefore, you may be required to provide information about your criminal history to be considered for this position. Employment and Professional References Required.