Medical Records Coordinator - Bear Creek Nursing

Job qualifications: Ability to establish procedures and to suggest changes for smoother operations. • Able to understand the Medical Record Systems, including filing and electronic medical records. • Understand and utilize medical terminology, ICD-10-CM coding principles, concurrent and discharge analysis procedures, medical legal aspects, and possess management skills for a nursing facility. • Possess personal attributes to include professionalism, neatness, accuracy. • Must present a professional appearance. • Must be able to cooperate and work well with fellow employees. • Must be knowledgeable of computer systems, system applications, and other office equipment. • Must be able to meet all local health regulations and pass pre/post-employment physical exam, if required. This requirement also includes drug screening, criminal background investigation, and reference inquiry. Medical Record Technician • Certification as Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA). • Active member of the American Health Information Management Association (AHIMA) • Evidence of maintaining continuing education (CE) requirements of the American Health Information Management Association.

Duties and responsibilities: Assure that the resident is properly registered in the necessary indices of the facility (i.e. Resident Number Register and Master Patient Index). 2) Code admission diagnoses according to the ICD-10 CM coding guidelines and principles and enter codes into appropriate system(s), as required. 3) Assure the admission summary (face sheet) is complete. Medical Records Director Page | 2 4) Upon discharge, check records quantitatively to assure completeness and accuracy within thirty (30) days of the discharge or in accordance with state regulations. 5) Determine whether additional transfer data is needed and request from transferring facility if needed. Follow-up to assure receipt. 6) Check the record quantitatively on admission and periodically to assure completeness, accuracy and internal consistency. Report trends to the QA/QAPI committee. 7) Communicate with and assist the medical staff and allied health personnel in updating records. 8) Maintain the flow of the reports to the records. 9) Update diagnostic lists as changes occur by coding additional diagnoses documented by physician and resolving inactive diagnoses. Review diagnostic lists for accuracy in conjunction with the MDS schedule and sign for accuracy of MDS Section I, as required. 10) Check the discharge documentation quantitatively to assure completeness, accuracy, and internal consistency. 11) Obtain complete and accurate records within thirty (30) days of discharge or in accordance with state regulations. 12) Assure face sheet discharge information is correct. 13) Assure all required reports are in the record. 14) Follow appropriate procedures for closing a record permanently incomplete, if required. 15) Maintain the Resident Number Registry. 16) Verify the accuracy of the Master Resident Index upon admission and discharge of the resident. 17) Maintain overflow records. 18) Maintain a tracking system for physician visits and the authentication of orders. 19) Maintain accurate and timely Medicare certifications, as required. 20) Collect, correlate and maintain statistical data as needed. 21) Provide information, when requested, to those involved in research projects and studies with the approval of center administrator. 22) Assist the medical staff by providing data from the health records for Utilization Review, Triple Check, QAPI and various audits. 23) Maintain the numerical filing system for records. 24) Maintain the unit numbering system for record identification. 25) Maintain the necessary sign-out and follow-up controls of records. 26) Maintain and control release of information to authorized persons. 27) Type and/or transcribe reports of correspondence according to the needs of the HIM department. 28) Attend facility meetings as required. 29) Orientation of new staff members to the HIM department. Orientation and training of nursing and ancillary departments involved in documentation process. This will involve both state and Federal regulations and center policies and procedures, as well as documentation recovery education. 30) Ensure medical record copies are provided per policy and/or regulation to the appropriate resident and/or resident representative. 31) Ensure medical record copy fees are charged and collected per policy. 32) Ensure legal medical record requests are copied, prepared neatly, reviewed prior to delivery and sent/delivered in the specified time frame