Medical Records

The Medical Records Coordinator is responsible for preparing, compiling, maintaining,

storing and retrieving medical records in a timely and accurate manner.

Essential Duties

1. Maintains a qualitative and quantitative audit/quality monitoring process. Reports

findings periodically and as requested and assists with ensuring follow-up/corrections

are completed.

2. Maintains security of health information systems and medical records.

a. Verify physical protection is in place to prevent loss, destruction and

unauthorized use of both manual and electronic records.

b. Verify Facility safeguards are in place such as record sign-out systems.

c. Verify systems are in place for securing file cabinets and file rooms where

overflow and discharge records are stored.

d. Verify systems are in place to maintain confidentiality/privacy of both manual

and electronic health information.

3. Manages the release of health information functions for the Facility including review

and processing of all requests for information.

4. Maintains Facility policies and legal requirements for release of information.

5. Maintains system for filing, retention and destruction of records in compliance with

State, Federal, and HIPAA guidelines.

6. Participates in meetings and committees as requested.

7. Provides in-service education as applicable on health information issues.

8. Provides orientation to new employees on topics such as the medical record

organization and content, record completion, confidentiality, HIPAA privacy and

security safeguards, documentation standards and error correction procedures.

Standard Requirements

1. Supports the Mission, Values and Vision of the Facility.

2. Is knowledgeable of resident rights and supports an atmosphere which allows for

the privacy, dignity and well-being of all residents in a safe, secure environment.

3. Supports, cooperates with, and implements specific procedures and programs for:

HISTORY:

(A) 8/2012

OSHA and safety, including universal precautions and safe work practices,

established fire/safety/disaster plans, risk management, and security, report and/or

correct unsafe working conditions, equipment repair and maintenance needs.

4. Adheres to:

a. Confidentiality of all data, including resident, employee and operations

data.

b. HIPAA regulations

c. Quality Assurance requirements and compliance with regulatory

requirements.

d. Compliance with current law and policy to provide a work environment

free from sexual harassment and illegal and discriminatory behavior.

e. Code of Conduct and Compliance Programs when performing job

functions

5. Supports and participates in common teamwork:

a. Cooperates and works together with all co-workers; plans and completes

job duties with minimal supervisory direction, including appropriate

judgment.

b. Uses tactful, appropriate communications in sensitive and emotional

situations.

c. Follows up as appropriate with supervisor, co-workers or residents

regarding reported complaints, problems and concerns.

d. Promotes positive public relations with residents, family members and

guests.

e. Completes requirements for in-service training, acceptable attendance,

uniform and dress codes including personal hygiene, and other work

duties as assigned.

f. Participates as assigned in the orientation of new staff and demonstrates a

positive, helpful, and enthusiastic attitude.

6. Immediately reports incidents of alleged resident abuse or neglect or alleged

violations of residents’ rights to Director of Nursing or Executive Director.

7. Knowledgeable of age specific developmental factors specific to adult and

geriatric residents (i.e. physical, cognitive and socialization factors) in planning

delivery of care.

8. Maintains current practice standards or changes by participating in educational

opportunities provided by the Facility and outside resources.

Other Duties

Perform tasks which are supportive in nature to the essential functions of the job, but

which may be altered or redesigned depending upon individual circumstances. Performs

other work duties as assigned.

HISTORY:

(A) 8/2012

Qualifications

Education/Training: Preferred credentialing as a Registered Health Information

Administrator (RHIA) or a Registered Health Information Technician (RHIT). 12 months

prior experience in medical records department preferred.

A.D.A.A.A ((Americans with Disabilities Act) as amended) REQUIREMENTS:

Must be able to bend, stoop, push, pull, and walk and stand for most of the working day.

Requires manual dexterity sufficient to provide hands-on care to residents as well as to

operate standard office machines such as fax, telephone, etc. Requires normal range of

hearing and vision. Must be free from communicable diseases that post a “direct threat”

to the health or safety of others and which cannot be eliminated by a reasonable

accommodation. Must be able to lift a minimum of 30 pounds. Must be able to carry and

transport supplies. Must be able to pass a post-offer, pre-employment physical health

examination as a condition of employment. Must be capable of performing the essential

functions of the job, with or without reasonable accommodation(s).

Skill(s): Must possess proficient reading, writing, grammar, and mathematics skills;

proficient interpersonal relations and communication skills; decision-making skills, basic

computer skills; and be able to operate various medical and/or office equipment. Must

demonstrate knowledge of safety techniques. Must be able to communicate in English,

both verbally and in writing, and possess sufficient communication skills to perform the

tasks required.

Experience: Previous experience of at least 12 months preferred. Understands electronic

information systems used in long term care and demonstrates good computer skills.