Medical Records
Kingston Healthcare - Ashland, OH

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The purpose of this position is to implement facility policies and procedures to organize and maintain resident medical records in compliance with federal, state and local laws and regulations and to protect the confidentiality of resident medical records by maintaining systems of secure storage, distribution and retrieval.

High School diploma or G.E.D.

Minimum one year experience in medical records management including IC9-9 coding experience, preferably in Long Term Care.

Must be able to speak, read and understand English, follow written and verbal directions and be able to write legibly. Must have computer skills sufficient to format, create and document tracking documents and to take courses on a web-based employee training program.

Requires attention to detail, the ability to set and meet deadlines and follow up on multiple, concurrent tasks.

Have a positive attitude toward the elderly.

Visual acuity to determine the accuracy, thoroughness and quality of work performed. Aural acuity to receive detailed information through oral communication, including telephone. Must be able to gather information verbally and prepare written summaries of information received verbally or via phone.

Organize and maintain the facility's medical records in compliance with policies and procedures.

Protect medical record information from loss, damage or destruction prior to expiration of retention period.

Protect the confidentiality of medical records.

Audit medical records for completeness and accuracy and assume accountability for obtaining missing information, returning incomplete records to the responsible staff person, and tracking receipt of timely and late documentation.

Implement record system as trained by the consultant and automate records as required.

Required Skills

Treat residents, guests and coworkers with genuine care and courtesy.

Resolve differences in a manner that strengthens the team.

Accept responsibility for own behavior and not shift blame to others.

Be flexible and open to working in a changing environment.

Recognize the contributions of co-workers.

Assure all resident medical information is protected and kept confidential.

Protect medical records from loss, damage or defacing.

Track retention periods as defined by law and regulation and prepare documents for confidential destruction when appropriate.

File medical records timely and accurately.

Retrieve records promptly upon request of authorized persons or agencies.

Identify missing, incomplete and late documentation and track receipt, involving the Director of Nursing as needed.

Identify inaccuracies in medical records and use determination to obtain corrections.

Implement facility policies for advising all disciplines of documentation needing to be completed or updated.

Mail and track receipt of forms requiring physician signature or input to extent permitted by regulation.

Maintain accurate resident census report and distribute to designated individuals.

Maintain discharge analysis and disease index as required.

Complete all information in master resident index file.

Notify Administrator of all requests for information from Medical Records.

Answer correspondence regarding release of information from medical records.

Prepare records in answer to subpoenas.

Record, type and file minutes for assigned committees.

Ensure Medicare residents have timely certification/recertification forms signed by attending physicians.

Enter data timely, accurately and completely, print forms and reports as scheduled or assigned, and assist with quality assessment and assurance studies.

Required Experience

Minimum one year experience in medical records management including IC9-9 coding experience, preferably in Long Term Care.

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