Medical Records Non Licensed

JOB SUMMARY:

The Medical Records Department participates in all activities related to the establishment, maintenance, and closing of resident medical records in accordance with facility policies and regulations.

EDUCATION:

High School diploma required. Medical Records certification preferred, but not required.

Must continue to maintain background checks in good standing according to the requirements of Texas Department of Aging & Disability Services (DADS).

QUALIFICATIONS:

1. Must have computer skills and knowledge in filing, medical terminology, ICD-9 coding, and other clerical functions.
2. Strong organizational skills and attention to detail.
3. Considerable initiative and judgment is needed.
4. Must be able to communicate in English, both verbally and in writing, and possess sufficient communication skills to perform the tasks required.

RESPONSIBILITIES:

1. Sets up residents medical records; collects information from nursing staff, physicians and other sources, updates records, thins charts, and closes charts when necessary.
2. Monitors and audits records for completeness and accuracy, and thins charts in accordance with facility policy and regulations.
3. Processes transfer or discharge records and maintains appropriate records on former residents.
4. Assists with all medical record requests from residents, family members, insurance companies, legal authorities, etc. according the company policy.
5. May assist in the ordering, stocking, and maintaining inventory of nursing supplies.
6. Ensures understanding of, and compliance with, all rules regarding residents rights and HIPAA regulations.
7. Performs other duties as assigned by Supervisor.

PHYSICAL DEMANDS:

Use the percentages range as follows:

0%

Never

1

-

33%

Occasionally

34

-

66%

Frequently

67

-

100%

Continuous

Requires full range of body motion including:

1.

Standing/Walking:

Frequently:

Administrative filing; running off copies on copier; faxing copies; delivering/ret