Medical Records

Job Description

Job Description

Schedule:

Monday-Friday 8am-5pm 

Position Description

Responsible for maintaining resident medical records in accordance with State and Federal regulations, professional standard of practice and company policy and procedure. Responsible for ensuring the management and accuracy of medical resident records from pre-admission to post discharge.

Principal Responsibilities

• Manages resident health information by ensuring resident records remain accurate, complete, current, confidential, and are compliant with federal and state regulations, HIPAA, and company policies and procedures.

• Ensures accurate and current diagnostic coding to assure appropriate billing, to maximize accounts receiving and improve cash flow.

• Establishes and executes procedures in the collection, coding and indexing, and the filing/retrieving of medical records; Performs ICD coding; creates medical records for all new admissions.

• Must be knowledgeable on federal and state laws regarding medical records; Ensures resident records are maintained accurately and timely according to local, state and federal regulations; Performs monthly audits on: admissions, discharge and routine Quality Assurance

• Reviews and audits admissions, discharges, change of condition, and other pertinent records on nursing units; Performs routine audits of medical records upon admissions, throughout the stay, and discharge to monitor compliance with policies regarding documentation, physician visits, timeliness, etc.

• Other duties, responsibilities and activities may change or assigned at any time with or without notice.

Qualifications

• RHIA or RHIT credential preferred.

• Minimum of 2 years’ experience in medical records in skilled nursing facility or healthcare related field.

• Experience with ICD coding preferred.

• Knowledgeable of medical terminology, laws, and regulations, as they pertain to long term care.

• Possess effective communication skills to maintain positive relationship with residents, families, staff, physicians, consultants, providers, and governmental agencies, their representatives and the community.

• Maintain neat, well-groomed and professional appearance.

Robinson Oaks Wellness and Rehabilitation provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.