Fully vaccinated against COVID-19 including booster shots
Strong organizational and office technology skills
Knowledge of HIPAA and client confidentiality laws
Proficient in medical terminology
Comfortable collaborating with healthcare professionals
Leadership skills
Detail-oriented
Responsibilities
Comply with attendance policy for regular and punctual attendance
Maintain daily admission and discharge log for residents
Prepare charts for admission with required documentation
Check charts on new admissions daily until paperwork is complete
Assemble and audit discharged residents' records
Input physicians' orders via the Medical Records Accu-Care system
Participate in Quality Assurance Program and committee meetings
Benefits
Opportunity to work in a collaborative healthcare environment
Engagement in quality assurance and improvement initiatives
Access to ongoing training and professional development
Potential for leadership growth within the organization
Supportive team culture focused on patient care
Full Job Description
The Medical Records Clerk primarily compiles and maintains medical records of patients of health care delivery system to document patient condition and treatment.
Medical Records Director Requirements
Must be familiar with PCC (Point Click Care System)
Fully vaccinated against COVID-19 including Booster shots
Strong Organizational and Office Technology Skills
Knowledge of HIPPA and Client Confidentiality Laws
Proficient in Medical Terminology
Comfortable in Collaborating with Healthcare Professionals
Leadership skills
Detail Oriented
Primary Medical Records Director Responsibilities
Complies with the facility's attendance policy requiring regular, reliable, and punctual attendance
Maintains daily admission and discharge log for each resident
Prepares charts for admission with chart order form in front of chart
Checks charts on new admissions daily until all below required paperwork has been completed
Prepares all charts with tabs following chart order sequence
Assists with paperwork on new admissions
Prepares all forms in the chart with resident identification information
Assembles and audits discharged residents' records
Prepares computer sheets on scheduled dates for physician recaps and inputs physicians' orders via the Medical Records Accu-Care computer system
Operates computer to process, store, and retrieve health information
Completes recaps on timeline agreed upon by Director of Nursing
Completes audit schedule each day, week, and month
Audits charts
Participates in the Quality Assurance Program and Utilization Committee Meetings and passes CQI
Follows up on all consultant/QA recommendations
Utilizes medical records procedure manual as needed
Responsible for maintaining up-to-day inventory of facility forms
Attend mandated meetings: daily standup, weekly PPS, and monthly triple-check
Performs other duties or functions as assigned by the Administrator
Other Responsibilities
Ability to pull multiple reports using PCC system
Assists with paperwork on new admissions and discharges
Utilizes medical records procedure manual as needed. Does daily audits as assign
Prepares files, records and logs under the supervision of the Medical Records Designee
Requires attention to detail, lots of uninterrupted time at a desk with computer, and reliability
Employees must be able to maintain consistent attendance
Other duties may be assigned
PAY SCALE:
Depending on a number of factors, including, but not limited to location, regularly scheduled work shift, knowledge, skills, experience, and expertise.
