A long-term care facility on the South Shore of Long Island, NY is looking for a Full-Time Medical Records Clerk. Come join our team of professionals!
MEDICAL RECORDS JOB RESPONSIBILITIES:
- Responsible to abstract data and compile statistical reports as required.
- Maintain an appropriate filing system for both in-house and discharges residents.
- Responsible for notifying physicians of incomplete medical records. (Discharge summary must be completed within 14 days).
- Will notify appropriate disciplines of non-compliant areas noted in the chart.
- Assemble, audit, complete and file residents’ discharge records within 30 days.
- Audit in-house records for accuracy and completeness according to the established facility schedule.
- Maintain medical records in accordance with current laws and regulations and professional practices.
- Responds to chart requests from regulatory agencies, legal departments, service providers, etc.
- Works cooperatively with nursing and the interdisciplinary team in maintaining medical charts of the residents.
- Develops and maintains a good working rapport with interdepartmental personnel, as well as other Facility departments.
- Participates in Quality Assurance and Improvement and other committees as designated.
- Ensures that resident/patients rights are maintained.
- May photocopy records and documents for billing and/or legal.
- Identify different report types. Identify and place in order under chart divider.
- Sort and deliver patient charts to appropriate locations. Pick-up charts upon request. Re-file returned charts.
- Demonstrates knowledge of, use and maintenance of technical equipment.
- Answer medical records telephone and respond accordingly.
- Ensure that charts are “thinned or debrided” as per protocol.
- Periodically checks the chart order and filing of documents.
- Understand archive chart process and procedures.
- Demonstrates knowledge of filing and policies and procedures.
- Mentor all staff to ensure proper policies and procedures are followed pertaining to medical charts.
- Provide facility with an efficient system for maintaining, filing, locating, logging, retrieving and delivering resident medical records.
- Assures system for recap of MD orders is completed monthly, to provide the nursing department with medication, treatment, and restorative documentation records.
- Keeps supervisor informed of problems or issues.
- Monitors supplies needed and anticipate future need of required supplies.
- Requests information from various departments; responds to correspondence requests.
- Maintains interpersonal relationship with patients, families, peers, staff and medical/professional staff.
- Ability to organize, synchronize, and maintain records of both the in-patient and out-patient consults
- Attends required in-services.
- Abide by facility’s policies (I.e. Procedure for re-admission, filing of medical records, procedure for discharge records/charts/summaries, procedure for death records, Sign-out control book, Discharge control book, security and proper storage of medical records, authorization requirements for retrieval of medical records to outside source, correction of incomplete charts/records, etc.).
- Gives appropriate notice of absenteeism and does not abuse time off benefit
- Respects the patient’s rights to confidentiality at all times.
- Displays sensitivity to the needs of patients, visitors and co-workers.
- Greets and interacts with other with consideration, courtesy, and respect.
- Inputs/edits/retrieves computer on a daily basis.
- Performs other duties as directed as the need arises to assure optimum care of residents.
Team Dynamics:
- Effectively communicates with staff to accomplish goals and objectives.
- Creates a work atmosphere that promotes cooperation, respect, flexibility and teamwork amongst peers and staff.
Safety and Sanitation:
- Follow all established safety procedures and precautions when operating equipment.
- Report equipment malfunctions or breakdowns to the program manager as soon as possible.
- Report all unsafe/hazardous conditions to the program manager immediately.
Customer Service:
- Maintains an adequate liaison with families, residents and patients.
- Demonstrates awareness, respect and concern for internal customers (coworkers) and external customers (i.e. patients, residents, families, physicians, referral sources)
Residents' Rights:
- Maintains CONFIDENTIALITY of all resident care information to assure resident rights are protected.
- Assures that the resident's rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are followed.
Attendance:
- Observes rules, policies and regulations with regard to attendance, punctuality, appearance and professional attitude as established by the facility.
Miscellaneous:
- Conforms to the HIPAA Compliance Program and applicable facility policies for patient privacy.
- Conforms to the facility’s Corporate Compliance Program to include Conflict of Interest and Code od Conduct
- Conforms to the facility’s policies and procedures.
We are an EOE.
INDMISC
Job Type: Full-time
Pay: From $20.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Paid time off
Experience:
- Medical records in healthcare setting: 2 years (Required)
Work Location: In person
