SUMMARY: The Medical Records Manager is responsible for the day-to-day medical records maintenance in accordance with current acceptable records management procedures and confidentiality practices and as may be directed by the Administrator. ESSENTIAL FUNCITIONS: NOTE: Laguna Rainbow Corporation may unilaterally change the requirements of this job description at any time. To perform this job successfully, […]
SUMMARY: The Medical Records Manager is responsible for the day-to-day medical records maintenance in accordance with current acceptable records management procedures and confidentiality practices and as may be directed by the Administrator.
ESSENTIAL FUNCITIONS: NOTE: Laguna Rainbow Corporation may unilaterally change the requirements of this job description at any time. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. These include, but are not limited to, the following:
Administrative Functions:
File all patient data upon receipt of information
Operate paging/telephone system as required.
Answer telephones; determine nature of call and direct caller to appropriate individual or department-if not for Medical Records.
Deliver and pick up files as needed.
Receive inquiries and release information in accordance with established policies and procedures.
Prepare filing statistics.
Perform routine audit of all resident’s charts, monthly, physician services: report discrepancies found through audits to the Director of Nursing/Administrator
Respond to calls from individuals who have questions about medical records.
Give directions/information to visitors, guests, residents, sales representatives, etc. as directed by Supervisor.
Request additional information as needed for completing the medical record.
Photocopy records as needed for legal procedures.
Retrieve archived records upon request from external/internal sources.
Create charts for new admissions.
Conduct QAPI rounds as scheduled, normally second Wednesday of each month.
Assist with administrative duties as directed. (Includes typing, filing, posting accounts, meeting schedule.)
Safeguard medical records against loss, destruction or unauthorized use.
Provide adequate space and equipment to efficiently review, index, file and prompt retrieve the medical records.
Operate copier, office machines, etc., as directed.
Operate computer as directed.
Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.
Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
Report any known or suspected unauthorized attempt to access facility’s information system.
Other related duties and responsibilities that may become necessary or appropriate.
Complete discharge filing and discharge audit.
Track medical director/physician assistant visits and documentation.
Fax requested information to Physician offices.
Track annual H&Ps and new admit H&Ps for Medical Director.
Comply with weekly angel rounds. Angel rounds documents are to be submitted to the Administrator no later than the close of business on Fridays.
Email is to be checked daily throughout the day and respond to email on a timely basis.
The Director is to attend all Mandatory meetings, with no exceptions (unless approved by the Administrator)!! Morning Stand-up is a MUST!!
Submit department QAPI data in a timely manner.
Personnel Functions:
Report suspected or known incidence of fraud to Administrator.
Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screensaver activates within established facility policy guidelines.
Staff Development:
Attend and participate in in-service educational classes and on-the-job training programs as directed.
Attend and participate in workshops, seminars, etc., as approved.
Create and maintain an atmosphere of warmth, personal interest, and positive emphasis, as well as a calm environment throughout the facility.
Attend and participate in facility mandatory in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, etc.).
Safety and Sanitation:
Follow all established safety procedures and precautions when operating office equipment.
Report equipment malfunctions or breakdowns to your supervisor as soon as possible.
Follow established ergonomics policies and procedures governing lifting techniques, repetitive tasks, and the use of safety equipment and supplies to prevent work-related injuries and illnesses.
Report all unsafe/hazardous conditions to your supervisor immediately.
Equipment and Supply Functions:
Ensure administrative supplies have been replenished in work areas as necessary.
Use office supplies in an efficient manner to avoid waste.
Request repairs for office equipment as necessary.
Ensure that work/assignment areas are neat, clean, and office.
equipment is covered before leaving such areas on breaks, end of workday, etc.
Budget and Planning Functions:
Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
Resident Rights:
Maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information.
Knock before entering a resident’s room.
Ensure that the resident’s rights to fair and equitable treatment, self-determination, individuality, privacy, property, and civil rights, including the right to wage complaints, are well established and always maintained.
Report all allegations of resident abuse and/or misappropriation of resident property to Administrator Immediately.
Perform additional duties as assigned.
REQUIRED QUALIFICATIONS (includes education, skills, and experience):The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
High school diploma or its equivalent.
Must have, as a minimum, one year performing clerical duties related to the essential functions of position.
Ability to read, write, speak, and understand the English language.
Intermediate to advanced skill level in Microsoft Office or similar software applications.
Ability to use office equipment such as computers, phones, photocopiers, filing cabinets and fax/scan machines.
Data entry skills.
The ability to make independent decisions when circumstances warrant such action.
Excellent verbal and written communication skills.
Ability to multi-task, work successfully under pressure, and effectively prioritize and manage time and workload.
Requires well-developed social skills the ability to interact tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.
Ability to maintain a productive working relationship with the medical profession and other health related facilities and organizations.
The ability to create and maintain an atmosphere of warmth, personal interest, and positive emphasis, as well as a calm environment throughout the facility.
Leadership skills and ability and willingness to work harmoniously with and supervise other personnel.
Must be able to act with patience, tact, cheerful disposition, and enthusiasm, as well as be willing to assist residents based on whatever maturity level at which they are currently functioning.
Willingness and ability to seek out new methods and principles and be willing to incorporate them into existing activity services.
Possession of excellent communication skills and ability to convey information concerning a resident’s condition.
Must have a good driving record, valid, driver’s license, vehicle insurance and a reliable vehicle.
WORKING CONDITIONS AND PHYSICAL EFFORT: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Will have some repetitive hand and arm motions and prolonged periods of sitting and/or standing.
While performing the duties of this job the employee is regularly required to stand; walk; talk, listen, reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl.
This position requires frequent manual dexterity in combination with eye/hand coordination such as keyboarding and handling of equipment.
Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus.
Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination.
Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet.
May be necessary to assist in the evacuation of residents during emergency situations.
Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as reactions from dust, disinfectants, tobacco smoke, and other air contaminants.
Is subject to pressure from multiple/emergency calls.
Tasks assigned to this position may involve potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants and hazardous chemicals.
The noise level in the work environment is usually low to moderate.
BACKGROUND INVESTIGATION REQUIREMENTS:
Laguna Rainbow Corporation has a strict policy for background investigation processes. Every position is reviewed and screened. This includes Onsite pre-employment drug screening, criminal background check (includes fingerprint) and license verification.
Type of Background Check
Required
Pre-Employment Drug Screening
X
Background Investigation through Department of Health “DOH” – Fingerprint Verification (Criminal Check, Abuse and Neglect Check, Sex Offender Check, Civil Court Check and Tribal Criminal Check)
