- Assist in planning, developing, organizing, implementing, evaluating, and directing the medical records section in accordance with established policies and procedures. (Includes department polices and procedures, job descriptions, etc.).
- Assist in establishing procedures to be followed in the collection, coding and indexing, and the filing/retrieving of medical records.
- Assist the medical records clerk as required.
- Advise the administrator on federal and state laws concerning medical records.
- Review discharge and death records, as well as records on the nursing units.
- Review department policies and procedures, at least annually, and participate in making recommended changes.
- Collect, assemble, check, and file resident charts and personnel records as may be necessary.
- Ensure that incomplete records/charts are returned to nursing service for correction.
- Assist in developing procedures to ensure records are properly assembled, coded, signed, indexed, etc., before filing.
- Ensure established policies and procedures for the medical records section are followed by all personnel.
- Assist in establishing procedures to ensure that charts/records are not taken from the section except as authorized. Periodically check such records to assure this policy is being followed.
- Assist the medical records clerk in maintaining a record of authorized information taken from charts/records (i.e., type information, name of recipient, date, department, etc.).
- Abstract information from records as authorized/required for insurance companies, Medicare, etc.
- Assist in indexing medical records as necessary.
- Ensure that registries are properly maintained for admission and discharge of residents.
- Prepare medical records for court trials as required.
- Assume the authority, responsibility, and accountability of the medical records.
- Assist in the development and implementation of our written medical records policies and procedures.
- Devote such time, energy, and skill necessary to maintain accurate medical records.
- Provide written, dated, and signed reports to the administrator of each consultation visit.
- Obtain and maintain a suitable professional liability and malpractice insurance policy.
- Other related duties and responsibilities that may become necessary or appropriate.
The employer for this position is stated in the job posting. Ensign Services, Inc. provides recruiting services for operations in the skilled nursing, assisted living, home health and hospice industries.