POSITION TITLE:
The Medical Records Designee job description will provide the scope of the position for the facility Occupational Exposure:
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POSITION SUMMARY:The Medical Records Coordinator maintains customer records containing all items required by State and Federal Regulations, and facility policies. He/she provides records information for summaries and insurance reports, as may be required.
SPECIFIC EDUCATION/VOCATIONAL REQUIREMENTS:
1. The Medical Records Coordinator must have a high school degree.
2. Experience with coding and abstracting is required and basic courses or experience pertaining to the position is preferred.
3. This position requires that the employee is able to read, write, speak and understand the spoken English language to ensure the safety and well being of our patients and visitors at the work site when responding to their medical and physical needs.
4. Must provide verification of TST (tuberculin skin test) as required by state law and in accordance with Company policy. TSTs will be administered at the work site if required.
JOB SKILLS:
1. Must have knowledge of medical and anatomical terminology.
2. Must have knowledge of coding and filing systems.
3. Must have knowledge of the rules of grammar, spelling and punctuation.
4. Must be accurate and detail oriented.
5. Must possess the ability to positively interact with personnel, customers, family members, visitors, government agencies/personnel and the general public.
PERFORMS RELATED DUTIES:
1. Interacts with customers, families, visitors, facility and Reliant subsidiary personnel;
2. Carries out other tasks as requested in situations where hands-on intervention/participation may be required.
RESPONSIBILITIES/ACCOUNTABILITIES:
1. Maintains accurate order of open charts;
2. Prepares closed charts;
3. Assumes responsibility for diagnostic admission and discharge coding index;
4. Ensures that all Physician Orders are signed in a timely manner;
5. Ensures all Medicare Certifications and Re-certifications are signed in a timely manner;
6. Notifies MDs in reference to compliance of customer visits and progress notes;
7. Communicates with Pharmacy in reference to additions/deletions of customer MARs, POFs;
8. Maintains forms/office supplies inventory under the direction of the Director of Nursing or his/her designee;
9. Answers telephone inquiries and may answer correspondence;
10. Performs miscellaneous duties pertaining to medical records;
11. Obtains all appropriate departmental and physicians' signatures on discharge charts within 30 days of discharge;
12. Puts Customer Service First: Ensures that customers and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals' needs and rights;
13. Performs other duties as requested.
