Lord Chamberlain Nursing and Rehabilitation Center -
Medical Records
- Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.
- Assist in organizing, the medical records section in accordance with established policies and procedures.
- Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
- Collect, assemble, check and file resident charts as required.
- Ensure incomplete records/charts are returned to nursing service for correction.
- Assist the Medical Record Technician as necessary.
- Follow established policies and procedures for the medical records section.
- 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, Medicaid, VA, etc.
- Collect charts, assemble them in proper order, and inspect them for completion.
- Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
- Assist in admission, transfer and discharge procedures as necessary.
- Answer telephone inquiries concerning medical records functions. Prepare written correspondence as necessary.
- Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.)
- Assure that medical records taken from the department are signed out and signed in upon return to the department.
- File active and inactive records in accordance with established policies.
- Assume the administrative authority, responsibility, and accountability of performing the assigned duties of the Medical Records Clerk.
- Other related duties and responsibilities that may become necessary or appropriate to meet the administrative needs of this facility.
- Maintain loose filing in alphabetical order and process loose filing.
Admission Functions
- Maintain a supply of pre-filled charts for weekend and off-shift admissions/readmissions.
- Attach preadmission documentation to admission papers as appropriate and prepare medical records for admisssions based on policies/procedures.
- Process Admission problems to proper authority, i.e., supervisor, social service, nursing service, etc.
- Refer admission problems to proper authority, i.e., supervisor, social service, nursing service, etc.
- Follow Admission policies and procedures for informing appropriate departments of admissions/readmissions.
- Collect or receive discharge medical records from nursing office daily.
- Dismantle and create discharge medical record.
- Place active medical record in discharge order as stated in the medical record policies and procedures.
- Analyze medical records for completion and return to nursing office for completion as needed.
- File medical record as closed upon completion.
Maintain incomplete medical record file.
Educational Requirements
- Must possess, as a minimum, a high school diploma.
Experience
- Must have working knowledge of ICD-9-CM coding
- Must have a working knowledge of medical terminology.
- On-the-job training provided in medical record procedures.
- Computer Knowledge
Full time benefits
- Competitive pay
- Shift differentials
- Medical, Dental and Vision Insurance*
- PTO*
- 401 (k) with employer match*
- Employer Paid Life Insurance
- Paid Meal Period
- 8 Paid Holidays
- Employee Assistance Program
- Longevity Credit*
- Short- & Long-Term Disability*
Medical Records Clerk- Pay Rate