Medical Records Clerk - Boynton Beach, United States - Heartland Nursing and Rehabilitation Center

Description

Department

Administration/Nursing

Reports to

Administrator/Director of Nursing

Reporting to this position

None

Job Classification

Department Staff

Position Purpose

Maintains resident medical records and health information systems in accordance with current federal and state guidelines and established policies and procedures.

Required Qualifications

• High school diploma or equivalent
• Minimum of 2 years' administrative experience preferred.
• Working knowledge of medical terminology, anatomy and physiology, coding, and other aspects of health information preferred, but not required.

Major Duties and Responsibilities

Organizes, plans and manages the medical records department in accordance to established policies and procedures.

Ensures resident health information is protected and not disclosed unless by permission or with established policies and procedures.

Assigned Tasks

• Retrieves resident records (manually/electronically). Delivers as necessary.
• Files information such as nursing notes, assessments, progress notes, lab reports, x-ray results, correspondence, etc., either manually or electronically into resident charts.
• Collects, assembles, checks, and files resident charts.
• Ensures incomplete records/charts are returned to appropriate department or personnel for corrections.
• Ensures resident records are properly completed, assembled, coded, etc., before filing.
• Extracts information from records for insurance companies, Medicare, Medicaid, VA, etc., in accordance to established policies and procedures and privacy rules.
• Picks up and delivers medical records to designated areas as necessary.
• Answers telephone calls in regards to inquiries about medical records. Prepares written correspondence as necessary.
• Files active and inactive records as per established policies
• Completes portion of death certificates as indicated.
• Maintains logs of specific items as per established policies and procedures.
• Maintains requests for medical records forms and completes as necessary.

Additional Tasks

• Treats all residents with dignity and respect. Promotes and protects all residents' rights.
• Establishes a culture of compliance by adhering to all facility policies and procedures. Complies with standards of business conduct, and state/federal regulations and guidelines.
• Follows appropriate safety and hygiene measures at all times to protect residents and themselves.
• Maintains confidentiality of protected health information, including verbal, written, and electronic communications.
• Reports noncompliance with policies, procedures, regulations, or breaches in confidentiality to appropriate personnel. Reports any retaliation or discrimination to HR or compliance officer.
• Reports any allegations of abuse, neglect, misappropriation of property, exploitation, or mistreatment of residents to supervisor and/or administrator. Protects residents from abuse, and cooperates with all investigations.
• Reports any occupational exposures to blood, body fluids, infectious materials, and/or hazardous chemicals in accordance with facility policy.
• Participates in all life safety and emergency drills and trainings. Fulfills responsibilities as assigned during implementation or activation of the facility's emergency plan.
• Reports work-related injuries and illnesses immediately to supervisor.
• Follows established infection control policies and procedures.
• As a condition of employment, completes all assigned training and skills competency.

Personal Skills and Traits Desired/ Physical Requirements/Working Conditions

• Ability to read, write, speak and understand the English language.
• Must be a supportive team member, contribute to and be an example of team work.
• Ability to make independent decisions when circumstances warrant such action.
• Ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.
• Must have patience, tact, and willingness to deal with difficult residents, family and staff.
• Must be able to relay information concerning a resident's condition.
• Must not pose a threat to the health and safety of other individuals in the workplace.
• Must be able to move intermittently throughout the workday.
• Meets general health requirements according to facility policy, including medical and physical exams and checking immunity status to various infectious diseases.
• Ability to work beyond normal working hours and on weekends and holidays when necessary.
• Ability to assist in evacuation of residents during emergency situations.
• Ability to bend, stoop, kneel, crouch, perform overhead lifting and perform other common physical movements as needed for the position.
• May be subject to falls, burns from equipment, and/or odors throughout the day; encounter reactions from dust, tobacco smoke, disinfectants, and other air contaminants.
• Subject to exposure to infectious waste, diseases and/or conditions which include AIDS, Coronavirus, Hepatitis B, and Tuberculosis.
• May be subject to hostile or emotional residents, family members, visitors or personnel.
• Must be able to follow oral and written instructions.
• Must be able to move intermittently throughout the workday.
• Mainly works in office but may work throughout the facility.

Compliance as a Condition of Employment and Performance Appraisal

Agreement to abide by all standards, policies, and procedures of the facility, including the facility's compliance and ethics program, is a condition of employment. Compliance will be a factor in evaluating job performance. Violations, including failure to report violations, will result in disciplinary action, up to and including termination.

This job description is intended to convey the general scope of the major duties and responsibilities inherent in this position. Other tasks not listed here may be assigned by the Administrator. Periodic revision may be necessary to reflect changes in expectations placed on long term care by various governmental agencies. This job description will be reviewed and/or revised annually and as needed.

Individual performance will be evaluated using the following scale:

1. Unsatisfactory: Achieves results which are far less than the standards identified for the performance factors rated.
2. Needs Improvement: Achieves results which are less than the standards identified for the performance factors rated. Exhibits the potential to become a competent performer. May be new to job or need skill development.
3. Meets Standards: Achieves results which meet the standards identified for the performance factors rated. This rating is the expected level of performance.
4. Exceeds Standards: Achieves results which usually exceed the standards identified for the performance factors rated.

Reasonable Accommodation Statement

Consistent with the Americans with Disabilities Act (ADA) and [insert state civil rights law], it is the policy of [Facility Name] to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact [include name and/or department, telephone, and e-mail address].