Medical Records & Coordinator

• Respond to requests for medical record information by insurance companies, Medicare, Medicaid, Veterans Administration(VA)or healthcare providers as authorized and in accordance with the Health Insurance Portability and Accountability Act (HIPAA)privacy and security requirements.
• Ensure medical records are properly completed, assembled, coded, signed, indexed, etc., before filing.
• Assure that medical records taken from the department are signed out and signed back in upon return to the department.
• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.
• Audit and review electronic health record (EHR)documentation for accuracy and completion.
• Maintain medical health records in a manner that is consistent with administrative, legal and regulatory requirements and best practices.
• Complete medical record and documentation competencies as directed.
• Audit and thin medical records per facility policy and as directed.
• Coordinate with hospital and admission office regarding proper ICD-10 (International Classification of Diseases-Tenth Revision) coding as acceptable for Patient Driven Payment Model (PDPM)and other reimbursement methodologies.
• Return incomplete records/charts to appropriate departments or personnel for correction.
• Facilitate the transportation, retrieval and delivery of medical records from nursing units, chart racks, therapy or other facility designated locations while safeguarding protected health information (PHI).
• File or input information into resident charts as requested.
• Fulfill authorized medical records releases (hardcopy and electronic) as directed by facility policies in accordance with verified court-ordered request, legal request or as requested by appropriate and lawful means.

• Initiate and setup medical charts for all new patients including all required forms and computer profile setup per facility policies.
• Maintain a record of authorized information released from charts/records (i.e., type of information, name of recipient, date, department, etc.).
• Provide a complete and certified copy of the medical record within the timeframe allotted as required by facility policies, state and/or federal regulations.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.).
• Track physician certifications and recertifications as required for skilled nursing and rehabilitation services.
• Transcribe and type reports for physicians as necessary.
• Work in collaboration with medical record and clinical consultants in accordance with established facility policies.
• Work in collaboration with other departments to ensure that all required medical and admission paperwork is translated into all required languages spoken by residents of the facility.

• Works in office areas as well as throughout the facility.
• Moves intermittently during working hours.
• Is subject to frequent interruptions.
• Works beyond normal working hours and on weekends and holidays and on other shifts/positions as necessary.
• Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).
• Attends and participates in continuing education programs.
• Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday as well as to reactions from dust, disinfectants, tobacco smoke and other air contaminants.
• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
• Communicates with nursing personnel and other department personnel.
• Is subject to hostile and emotionally upset residents, family members, personnel, visitors, etc.
• Is involved with residents, family members, personnel, visitors, government agencies and personnel, etc., under all conditions and circumstances.
• May be subject to the handling of and exposure to hazardous chemicals.

• Must possess a working knowledge of medical terminology, HIPAA requirements, coding and indexing.
• On-the-job training provided in medical record and health information system procedures.

• Must be able to read, write, speak and understand the English language.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, visitors and the general public.
• Must be knowledgeable of medical terminology.
• Must possess the ability to work harmoniously with other personnel.
• Must possess the ability to minimize waste of supplies, misuse of equipment, etc.
• Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices.
• Be able to follow written and oral instructions.
• Be knowledgeable in computers, data retrieval, input and output functions, etc.
• Must not pose a direct threat to the health or safety of other individuals in the workplace.

• Must be able to move intermittently throughout the workday.
• Must be able to speak and write the English language in an understandable manner.
• Must be able to cope with the mental and emotional stress of the position.
• Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
• Must function independently, have personal integrity, have flexibility and the ability to work effectively with other personnel.
• Must meet the general health requirements set forth by the policies of this facility which include a medical and physical examination.
• Must be able to push, pull, move and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move and/or carry such weight a minimum distance of 50 feet.
• May be necessary to assist in the evacuation of residents during emergency situations.

Southern Oaks Care Center