We are currently seeking a Medical Records Technician to join our TRISUN Care Center - Windcrest team in San Antonio, TX!!!
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Prepares folders and maintains records of newly admitted residents and discharge residents.
Audits and reviews medical records for completeness, assembles records into standard order, and files records in designated areas according to applicable alphabetical and numeric filing system. This is done in a timely manner.
Audits and reviews medical records for completeness.
Codes diagnoses utilizing ICD-9 coding classification system and maintains the disease index as needed.
Provides nursing stations with proper chart and documentation forms.
Locates, signs out, and delivers medical records requested.
Organizes discharge records. Initiates and audits discharge summaries for completeness.
May be required to take pictures of Residents upon admission for medical chart.
Performs monthly thinning and filing of medical charts.
Processes daily mail to be sent to physicians and Nurse Practitioners for signatures.
Corrects physician’s phone orders daily.
Inputs Physician’s orders to create MARS and TARS for new admissions, readmissions and current residents.
Processes death report to NHIC in a timely manner.
Assists with monthly physician order reviews, and flow records for first of month initiation.
Prints monthly end of month MAR and TAR for nursing to review. After review, makes corrections and finalizes MAR and TAR.
Handles records requests in accordance with company policy.
Maintains organization of medical records per company guidelines.
Completes, maintains and distributes daily census listing, daily room assignment listing, physician/resident list and admission/discharge/transfer register.
Complies with Federal and State Regulations.
Verifies physician’s orders with nursing staff.
Distributes incontinence supplies to appropriate hall/resident.
Assists nursing with monitoring and tracking of physician orders and health and physical examinations each month.
May accompany residents to doctor’s office appointments.
Compiles statistical data such as admissions, discharges, and deaths as needed.
Operates computer to enter and retrieve data and type correspondence and reports.
Inventories and orders supplies for nursing department.
May be responsible for central supply which includes:
Takes inventory of and rotates stocked items daily, and maintains monthly inventory of all nursing supplies.
Orders and maintains inventory of supplies and fills requests according to procedures.
Place central supply and vendor orders on a weekly basis and ensures timely shipping of orders.
Unpacks and checks supplies upon receipt from vendors or other suppliers, and reports discrepancies in orders to Administrator.
Maintains confidentiality of necessary information.
Understands and adheres to the guidelines of “Residents Rights”.
Participates and attends scheduled in-services and staff meetings.
Performs Manager on Duty duties according to facility rotation.
Other duties as assigned.
Medical Records Clerk if applicable
Must have thorough knowledge and understanding of Medical Terminology and proven ability with basic PC knowledge and skills.
EDUCATION and/or EXPERIENCE
1 - 2 years’ previous experience with medical records in a healthcare setting
CERTIFICATES, LICENSES, REGISTRATIONS
Preferred Notary Public for State of Texas
PHYSICAL DEMANDS and WORK ENVIRONMENT
Employee is required to hear, speak, sit, stand, and walk daily. The position is located in healthcare facility environment. Employee may lift up to 40 pounds and/or transfer 100 plus pounds.