Summit LTC Hiring for Medical Records Job at Kingsland, TX Full Time

POSITION SUMMARY

We are looking for a skilled Medical Records Coordinator to become a part of our facility’s compassionate care-giving team. The successful candidate will be responsible for the maintaining medical records in accordance with federal and state guidelines, as well as established policies and procedures, to ensure that a complete medical records program is maintained and professional standards of practice. Facilitates effective communication of resident needs and issues to the team and fosters positive change, professional/program growth and teamwork.

We’re looking for a highly competent and well-organized professional who values safety, security and patient wellness above all else. We focus on providing the best care possible while ensuring patient satisfaction in every interaction. The Medical Records Coordinator is responsible for making sure those values are reflected in his or her staff at all times.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

• Receive and follow work schedule/instructions from supervisor and as outlined in established policies and procedures.
• Assist in organizing, planning and directing the Medical Records Department in accordance with established policies and procedures.
• Collect, assemble, check and file patient/resident charts and records as required.
• Ensure incomplete records/charts are returned to nursing service for correction.
• Ensure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of work day, etc.
• Assist in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.
• Follow established policies and procedures for the medical records section.
• Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.
• Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
• Maintain a record of authorized information taken from charts/records i.e., type of information, name of recipient, date, department, etc.
• Abstract information from records as authorized/required for insurance companies, Medicare, etc.
• Index medical records as directed by the Medical Records Consultant or Director.
• Maintain various registries as directed including register for admission and discharge of patients/residents.
• Establish and maintain personnel records for all employees.
• Establish and maintain patient’s master card file.
• Participates in the overall quality assessment and improvement program activities.
• Other related duties as may become necessary or as directed by your supervisor, department director, and/or Administrator.
• Perform miscellaneous duties pertaining to medical records and assist Business Office personnel as required/directed.
• Ensure that patient/resident rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints are followed.
• Assist in the orientation program for all personnel in accordance with our policies and procedures.
• Assist the medical records consultant as required.
• Perform secretarial duties for committees of the facility as directed.
• Maintain minutes of meetings/files as necessary.
• Develop and maintain a good working rapport with intra-department personnel, as well as other departments within the facility, to ensure that medical records can be properly maintained.
• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
• Maintain CONFIDENTIALITY of all pertinent patient/resident care information to ensure patient/resident rights are protected.
• Report equipment malfunctions or breakdowns to your supervisor as soon as possible.
• Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately.
• Ensure supplies have been replenished in work areas as necessary.
• Ensure that schedules are followed as outlined for respective shift/area.
• Attend and participate in in-service educational classes and on-the-job training programs.
• Attend and participate in workshops, seminars, etc., as approved.

PM21

Requirements:

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. 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.

EDUCATION and/or EXPERIENCE

High school diploma or relevant qualification.

• Must possess, as a minimum, a Nursing license from an accredited college or university, or be a graduate of an approved LVN/RN program.
• Possession of a current valid Texas driver’s license or regular means of transportation to and from work.
• One (1) year of experience as a nurse in a skilled rehabilitation, skilled nursing or Long-Term Care (LTC) environment preferred.
• One (1) year of experience with electronic medical records preferred.

KNOWLEDGE, SKILLS AND ABILITIES

• Must be able to read, write, and speak the English language.
• Must be capable of operating a personal computer to enter resident data as required by regulation and facility policy.
• Ability to read and comprehend simple instructions, short correspondence, and memos.
• Ability to type, take shorthand, and dictation.
• Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form.
• Ability to communicate orally and in written form effectively with all levels of employees, patients, families, and vendors.
• Ability to present information in one-on-one and small group situations to employees, patients, families, and vendors.
• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.
• Good understanding of medical and pharmacological terminology.
• Excellent problem solving/analysis/judgment skills and high level of attention to detail and accuracy
• Builds and maintains cooperative working relationships
• Must possess leadership and supervisory ability and the willingness to work harmoniously with professional and non-professional personnel.
• Establish and maintain effective working relationships with clients, supervisors, County employees, elected officials, law enforcement, other agencies, and the public.
• Resourceful, dependable and accountable
• Able to work a flexible schedule including evenings, weekends, and holidays.

CERTIFICATES, LICENSES, REGISTRATIONS

Must possess a current and active CNA, LVN or RN license to practice as a nurse in this state.

PHYSICAL DEMANDS/ WORK ENVIRONMENT

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.

Physical Requirements:

• Work requires physical activity including extended periods of walking and standing with occasional climbing, reaching, carrying, balancing, kneeling, crouching and bending.
• Must have the ability to frequently lift and/or carry equipment, files, and other materials weighing up to 50 pounds as well as push/pull up to 50 pounds of force with grip strength of 65 pounds.
• Must be able to assist in the evacuation of residents during emergency situations.
• Must be able to continuously perform simple manipulative dexterity tasks such as the equipment listed above as well as safety pin buckles and tie strings. Occasionally perform difficult manipulative tasks.
• Must be able to detect the smell of smoke, spoiled food, soiled linen, etc.
• The employee must be able to continuously hear normal sounds and voice patterns with some background noise. Must have adequate verbal instructions. Must be able to hear audible emergency signals, alarms, call, light indicators and to be able to answer the phone.
• Specific vision abilities required by this job include: Must be able to continuously notice a change in the resident (breathing, color, skin breakdown, etc.) Ability to focus and read a thermometer.
• Visual abilities, correctable to normal ranges, include close, distance and color vision, depth perception, and the ability to adjust focus.

The work environment characteristics described here are representative of those employee encounters while performing functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work Environment:

• Work is performed indoors in a health care facility.
• Work is performed during assigned shift; however, hours will occasionally include varied days, hours, holidays, weekends, and overtime as needed.
• The noise level in the work environment is usually moderate, but can occasionally be loud. Subject to frequent interruptions.
• Incumbents in this position may be exposed to infectious/communicable diseases, blood borne pathogens, and potential risk of injury from distraught individuals.
• Frequent exposure to chemical compounds of medication and treatments.
• Frequent exposure to microbial bacteria and other infectious agents inherent to care of ill residents.
• Continuous exposure to latex, Tyvex, plastic and/or materials which are used for personal protective equipment.
• Stress of working with sick residents and their families, combined with the resident who may be confused, irrational, highly agitate mood swings. (Frequently)
• Subject to involvement with personnel, visitors, state and federal agency personnel and residents.

Summit LTC Management, LLC is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

PI180683047