Medical Records Coordinator

Job Description

Job Description

Purpose of Your Job Position

As a Tandem Health Care Medical Records Coordinator, you are entrusted with the responsibility of caring for our residents, families, co workers, visitors and all others, as well as demonstrating in all interactions, Tandem Health Care's five core values of Compassion, Honesty, Integrity, Respect and Passion. The primary purpose of your job position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines as well as in accordance with our facility's established privacy policies and procedures. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results.

Delegation of Authority

As Medical Records Coordinator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for maintaining medical records in accordance with Federal, State and Corporate guidelines, policies and procedures. No supervisory function. This job description does not list all the duties of the job. You may be asked by the supervisors or managers to perform other duties. You will be evaluated in part based upon your performance of the tasks listed in this job description at anytime. This job description is not a contract for employment, and either you or the employer may terminate employment at any time, for any reason.

Duties and Responsibilities

Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures. Assist in organizing, planning and directing the medical records department in accordance with established policies and procedures. Maintain active and discharged medical records in accordance with established systems. Notify staff involvement of incomplete records via the established delinquency/deficiency system and/or quality improvement process. Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained. Assist in recording all incidents/accidents. File in accordance with established policies and procedures. Retrieve resident records (manually/electronically). Deliver as necessary. Files information such as nurses' notes, resident assessments, progress notes, laboratory reports, X-ray results, correspondence, etc., into resident charts. Collect, assemble, check and file resident charts as required. Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines. Ensure incomplete records/charts are returned to appropriate departments or personnel for correction. Maintain active and discharged medical records in accordance with established systems. Contribute to development and implementation of current medical records policies and procedures, which reflect adherence to corporate and external regulatory guidelines. Conduct and document regular review of active and discharge medical records to determine quality, accuracy and completeness of contents. Notify staff involved of incomplete record via the established delinquency/deficiency system and/or quality improvement process. Actively participate in the facility improvement process. Safeguard medical records information against loss, destruction or unauthorized access. Provide orientation and ongoing supervision to part-time and/or temporary support staff, as appropriate. Conduct and document annual performance evaluations on medical records support staff, if appropriate. Conduct in-service training sessions for clinical and other staff, as needed, on pertinent topics, such as confidentiality, documentation, release of information, etc. Establish and maintain compliance with recognized system for filing and accessing medical records. Review all records to assure ICD-9-CM coding is complete and accurate. Generate reports as required for the facility management information system. Respond to requests for medical record copies and provide material in accordance with applicable federal and state laws. Maintain a log of all requests. Thin charts per policy and place in active file. Assure an adequate inventory of medical records supplies. Assist with the resident admission process, when requested. Attend and participate in facility meetings, as required. Participate in relevant inservice education sessions. Access continuing education opportunities appropriate to responsibilities. Assist in the preparation for and participate in regulatory compliance surveys. Embrace Tandem Health Care's five core values of compassion, honesty, integrity, respect and passion, and incorporate them into the daily job function. Demonstrate respect and compassion in every interaction. Conduct oneself with the highest degree of honesty and integrity in every interaction. Demonstrate a passion for caring as evidenced by interactions with co-workers, residents, families and visitors. Perform other duties, as assigned.