Technician-Med Rec (Ellen Sagar Nursing Center)

Job Requirements Position Summary Responsible for the set up and retrieval of medical records, prepping, scanning and indexing, charting reports and monitoring for quality assurance. Maintains medical records in accordance with state and federal regulations as well as professional standards of practice and facility policies and procedures to ensure complete, timely, and accurate medical records. Professionally manages all aspects of the medical resident record from admission to discharge. Must be able to effectively communicate with physicians, other staff, vendors and other customers. Must be able to effectively observe timelines for chart audits for Medicare, Medicaid, Private Insurance, Medicare Advance. Assists with ordering of supplies for facility, ensuring proper documentation and ordering of those supplies. Must be able to effectively do a chart audit and scan appropriate materials into the medical record. Must be able to secure and retrieve files from storage company as requested.

Minimum Requirements Education

• High school diploma or equivalent required.

Experience

• Demonstrates skills in human relations and communication, both written and verbal
• Computer and electronic database experience required

License/Registration/Certifications

• N/A

Preferred Requirements Preferred Education

• Associate’s degree

Preferred Experience

• 2-3 years’ experience in Medical Records
• Six (6) months of medical records department experience preferred

Preferred License/Registration/Certifications

• CDM Coding

Core Job Responsibilities Clerical

• Proactively gathers resident demographic information from a variety of sources as needed to setup and complete resident file (whether paper and/or electronic as required); professionally interacts with physicians’ offices as needed
• Maintains master resident roster
• Initiates the medical record by creating and processing the resident care record folder
• Maintains record availability by processing charts into the department; using chart mark-off procedures; facilitating chart location activities
• Retrieves medical records by following chart-out procedures; documenting reasons charts cannot be retrieved for statistical and follow-up purposes.
• Tracks dictation and transcription to facilitate medical record completion
• Prepares records in response to requests for release of information, adhering to regulations on transmitting information
• Administratively supports resident care through medical records’ management with making copies as needed, faxing or mailing copies of information as requested and in accordance with regulations
• Assists with or orders supplies for the facility and ensures proper retrieval and documentation of those supply order

Quality:

• Ensures records and documentation is appropriately, timely and within regulations setup and processed
• Identifies and corrections problems through records monitoring
• Collects data on appropriate forms
• Demonstrates practices to maintain safe environment for self and others; verbalizes understanding of appropriate chain of command