Job Description

Position Summary

The employee is responsible for supporting the organization, maintenance, accuracy, confidentiality, and accessibility of resident medical records in accordance with established facility policies, procedures, and applicable regulations.

The employee will receive and follow work schedules and instructions from the supervisor and assist the Medical Records/Health Information Consultant, MDS Coordinator, and other facility departments as needed.

Essential Duties and Responsibilities

Medical Records Administration

• Receive and follow work schedules and instructions from the supervisor in accordance with established policies and procedures.
• Assist in organizing, planning, and directing the Medical Records Department.
• Assist the Medical Records/Health Information Consultant as required.
• Maintain meeting minutes and file documentation as necessary.
• Develop and maintain effective working relationships with interdepartmental personnel and other facility departments to ensure medical records are properly maintained.
• Assist in documenting incidents and accidents and file related information according to established procedures.
• Retrieve resident records manually or electronically and deliver them as necessary.
• File documentation in resident charts, including:
  • Nurses’ notes
  • Resident assessments
  • Progress notes
  • Laboratory reports
  • X-ray results
  • Correspondence
  • Other required medical information
• Collect, assemble, review, and file resident charts as required.
• Assist the MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.
• Ensure incomplete records or charts are returned to the appropriate department or personnel for correction.
• Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, and filed.
• Ensure resident charts and records do not leave the Medical Records Department unless authorized under facility policies and procedures.
• Maintain records of authorized disclosures of information, including the type of information released, recipient name, date, department, and other required details.
• Abstract information from records for authorized purposes, including insurance companies, Medicare, Medicaid, VA, and other approved entities, in accordance with applicable privacy requirements.
• Index medical records as directed by the Medical Records/Health Information Consultant.
• Maintain required registries, including admission and discharge records.
• Transcribe and type reports for physicians as necessary.
• Collect charts, organize them in the proper order, and review them for completeness.
• Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas as necessary.
• Enter resident information into the computer system and retrieve demographic or other authorized information as appropriate.
• Answer telephone inquiries related to medical records functions.
• Prepare written correspondence as necessary.
• Retrieve medical records when requested by authorized personnel, including physicians, nurses, government agencies, and authorized facility personnel.
• Ensure all medical records removed from the department are properly signed out and signed back in upon return.
• File active and inactive records according to established policies and procedures.

Privacy, Confidentiality, and Information Security

• Maintain the confidentiality of assigned user IDs and passwords used to access resident or facility information.
• Promptly report suspected or known unauthorized disclosure of passwords, access credentials, or protected information to the Administrator.
• Maintain the confidentiality of residents’ Protected Health Information (PHI).
• Promptly report suspected or known violations involving the disclosure of resident information.
• Report any known or suspected unauthorized attempt to access the facility’s information systems.
• Ensure unattended departmental computer workstations are properly logged off or protected by an automatic password-protected screen saver in accordance with facility policy.
• Assume the administrative authority, responsibility, and accountability necessary to perform assigned duties.

Committee Functions

• Perform secretarial duties for facility committees as directed.
• Collect, assemble, and compile records for committee review.
• Prepare reports for staff and other committees as requested.

Personnel and Compliance Functions

• Report known or suspected incidents of fraud to the Administrator.
• Report suspected or known fraudulent activity related to false billing, cost reports, kickbacks, or other improper financial practices.

Staff Development

• Attend and participate in mandatory facility in-service training programs, including training related to:
  • OSHA
  • Tuberculosis (TB)
  • HIPAA
  • Abuse prevention
  • Other required subjects
• Attend and participate in approved workshops, seminars, and continuing education programs.

Safety and Sanitation

• Immediately report unsafe or hazardous conditions and defective equipment to the supervisor.
• Follow all applicable facility safety and sanitation procedures.

Equipment and Supplies

• Report equipment malfunctions or breakdowns to the supervisor as soon as possible.
• Ensure supplies are replenished in work areas as necessary.
• Ensure work and assignment areas are clean and that records, files, and other materials are properly stored before breaks and at the end of the workday.

Other Duties

• Perform other duties as assigned.
• Carry out assigned responsibilities with the administrative authority, responsibility, and accountability delegated to the position.

Qualifications

Education and Experience

• High school diploma or GED required.
• Ability to type a minimum of 45 words per minute.
• Ability to use dictation equipment.
• Working knowledge of medical terminology required.
• Knowledge of anatomy and physiology, legal aspects of health information, medical coding, and indexing is preferred but not required.
• On-the-job training may be provided regarding medical records and health information system procedures.
• Working knowledge of computers, including data entry, information retrieval, input, and output functions.

Language Skills

• Must be able to read, write, speak, and understand English.
• Must be able to read and understand technical procedures and instructions.

Mathematical Skills

• Ability to apply basic mathematical concepts, including:
  • Fractions
  • Percentages
  • Ratios
  • Proportions
• Ability to apply these concepts to practical workplace situations.

Reasoning and Interpersonal Skills

• Ability to make independent decisions when circumstances require.
• Ability to interact tactfully and professionally with personnel, residents, visitors, and the general public.
• Ability to work harmoniously and effectively with other employees.
• Ability to minimize waste of supplies and misuse of equipment.
• Willingness to identify and adopt improved methods and practices when appropriate.
• Ability to follow written and oral instructions.
• Must be able to perform the essential functions of the position without creating a direct threat to the health or safety of others.

Physical Requirements

The employee must be able to:

• Move intermittently throughout the workday.
• Speak and write English in an understandable manner.
• Cope with the mental and emotional demands of the position.
• Possess adequate vision and hearing, with or without assistive devices, to perform essential job duties.
• Function independently and demonstrate integrity, flexibility, and the ability to work effectively with others.
• Meet the general health requirements established by facility policy, including required medical and physical examinations.
• Push, pull, move, and/or lift a minimum of 25 pounds to a height of at least 5 feet.
• Push, pull, move, and/or carry such weight for a minimum distance of 50 feet.
• Assist with resident evacuation during emergency situations when necessary.

Reasonable accommodations may be made for qualified individuals with disabilities to perform the essential functions of the position.

Work Environment

The work environment described below represents conditions an employee may encounter while performing the essential functions of this position.

The employee:

• Works in office areas and throughout the facility.
• Moves intermittently during working hours.
• May experience frequent interruptions.
• May be required to work beyond normal business hours, including weekends, holidays, and other shifts or positions as necessary.
• May be subject to call-back during emergency conditions, including severe weather, evacuation, or post-disaster situations.
• Attends and participates in continuing education programs.
• May be exposed to workplace hazards, including falls, equipment-related burns, odors, dust, disinfectants, tobacco smoke, and other airborne contaminants.
• May be exposed to infectious waste, diseases, and conditions, including tuberculosis (TB), HIV/AIDS, and Hepatitis B.
• Regularly communicates with nursing personnel and employees from other departments.
• May interact with residents, family members, personnel, and visitors who are emotionally upset or hostile.
• Works with residents, family members, facility personnel, visitors, government agencies, and other authorized parties under a variety of circumstances.
• May handle or be exposed to hazardous chemicals.

Additional Information

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this position at any time.

The essential functions and responsibilities described above may be modified as necessary due to reasonable accommodation, operational requirements, regulatory changes, or other appropriate circumstances.

This job description is intended to describe the general nature and level of work performed by employees in this position. It is not intended to represent an exhaustive list of all duties, responsibilities, qualifications, or skills required.

Equal Employment Opportunity

We are an Equal Opportunity Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other status protected by applicable law.