POSITION SUMMARY
Under the direction and supervision of the Executive Director, maintains medical records in accordance with facility policies and regulations
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Demonstrates knowledge of age specific developmental factors specific to adult and geriatric residents with regard to medical records duties in the nursing department
- Sets up residents’ medical records; collects information from nursing staff, physicians, and other sources and updates records, thins charts, and closes charts when necessary
- Monitors and audits records for completeness and accuracy and thins charts in accordance with facility policy and regulations, and provides information to business office
- Oversees/performs scheduling of MDS assessments for comprehensive care planning and Medicare
- Communicates the RUG score for Medicare to the Director of Nursing and documents the score on the Medicare log
- Processes transfer for discharge records and maintains appropriate records on former residents
- Performs other related duties as required or requested
MINIMUM QUALIFICATIONS (KNOWLEDGE, SKILLS, AND ABILITIES)
- High school diploma or equivalent or higher
- Medical records certification preferred
- Must be able to communicate verbally and in writing in English
PHYSICAL DEMANDS AND WORK ENVIRONMENT
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions.
Physical Demands – Office
While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or finger, handle, or feel objects, tools or controls. The employee is required to stand; walk; sit; reach with hands and arms and pull/push; climb or balance; and stoop, kneel, crouch, or crawl. The employee must lift and/or move up to 50 pounds without assistance and 51-100 pounds with assistance. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus
Work Environment – Office
This job operates in a professional office environment with minimal exposure to dust, chemicals or noise. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.
NOTE
This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at will” relationship.