Medical Records Designee / Unit Secretary

JOB DESCRIPTION

TITLE: Medical Records Designee

REPORTS TO: Administrator

I. JOB SUMMARY

Compile, process, and maintain the medical records of the facility in accordance with current Federal, State, and local standards, guidelines and regulations, and facility policies. Coordinate the processing of Medical Record Requests from residents, resident representatives and other outside entities in accordance with current Federal, State, and local standards, guidelines and regulations, and facility policy.

II. QUALIFICATIONS

A. High School Diploma / GED Required

B. Prior experience working in a long-term care facility a plus.

C. Must be able to read, write, and speak the English language in an understandable manner.

D. Must have exceptional organizational skills.

E. Must have a strong attention to detail.

F. Must have knowledge of medical terminology.

G. Must have the ability to follow directions and work independently with minimal supervision.

H. Must possess the ability to deal tactfully with residents, family members, visitors, personnel, government agencies/personnel and the general public.

I. Must have a basic working knowledge of working with computers and programs such as Microsoft Word and Microsoft Excel.

III. PHYSICAL REQUIREMENTS

A. Must be able to move intermittently throughout the work day.

B. Must possess sight/hearing senses, or use prosthetics that will enable these senses to function adequately so that the requirements of the position can be fully met.

C. Must function independently, have flexibility, personal integrity and the ability to work effectively with the residents, family members, personnel and support agencies.

D. Must be in good general health and demonstrate emotional stability.

E. Must be able to cope with the mental and emotional stress of the position.

F. Must be able to relate to and work with ill, disabled, elderly, emotionally upset and at times hostile people.

G. May be required to lift, push, pull, and move equipment, supplies, etc. in excess of fifty (50) pounds throughout the day.

H. Is subject to exposure to infectious waste, diseases, conditions, etc., including exposure to the (HIV) AIDS and Hepatitis B viruses.

IV. ESSENTIAL FUNCTIONS

A. Maintain resident medical records in the electronic medical records system

B. Follow up with appropriate Physicians for signatures on required documents

C. Scan paper documents into the residents electronic chart

D. Ensure that Medicare patients have timely certifications/re-certifications signed by the attending physician.

E. Release information to persons and agencies according to regulations and facility policies.

F. Protect medical record information from loss, defacing or destruction before the retention period ends.

G. Protect the security of medical record to ensure that confidentiality is maintained.

H. Assist residents and resident representatives with review of medical record when requested in accordance with Federal, State and local guidelines and facility policy.

I. Timely collect, process and track medical record requests from outside persons or agencies in accordance with facility policy and procedure.

J. Interface with the Legal department for collection and tracking of records related to pending litigation or legal requests.

K. Interface with the billing department for collection and tracking of records related to reimbursement.

L. Perform other related duties as assigned