Medical Records Specialist – West Monroe Guest House – West Monroe, LA

Responsible for maintaining and securing all written and electronic medical records in accordance with state & federal guidelines as well as nursing home established policies and procedures. Ensure that information contained in the records are complete, accurate, timely, and only available to authorized personnel.

DUTIES AND RESPONSIBILITIES:

Plan, develop, organize, implement, evaluate, and direct the medical records department in accordance with established policies and procedures and state and federal guidelines.
Protect security of medical records to ensure that confidentiality is maintained.
Set up clinical records for incoming residents.
File resident information in individual charts as needed.
Maintain established medical record files.
Thin current medical records when needed.
Audit current medical records on admission, quarterly, readmission, and discharge.
Conduct routine audits of medical records for required documents and signature(s) and ensuring its’ confidentiality.
Monitor physician’s progress notes, reports, and obtain physician signatures when required.
Performs a variety of time sensitive functions associated with our Electronic Health Records including preparing, reviewing and following up on Plan of Care and Face to Face forms to obtain timely signatures as required by regulation.
Verifying that electronic health records meet quality indicators for processing and verifying resident/patient physician’s address and telephone contacts.
Review discharged and death records, as well as records on the nursing units.
Ensure resident charts and records are collected, assembled, audited, and filed.
Maintain a record of authorized information taken from charts/records (i.e., type information, name of recipient, date, department, etc.).
Abstract information from records as authorized/required for insurance companies, Medicare, etc.
Prepare medical records as required for legal proceedings.
Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed. Attend such meetings as may be necessary or appropriate.
Ensure that work areas are clean and that records are properly stored.
Mail out health care provider orders for signature.
Perform Chart Audits under the direction of the DON and ADON.
Request clinic progress notes from visits to dentist, podiatrist, and optometrist; and other paperwork from ER visits.
Copy & file clinical documentation; secure clinical staff signatures; fax and transmit documents to billing department.
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