Medical Records
Carespring Health Care Management, Cincinnati, OH, United States
Position Summary
Pay $14 - $22 depending on certification or credentials. This Medical Records Coordinator will maintain medical records in accordance with state and federal regulations and professional standards. The role requires working every other weekend.
What We Offer
Competitive wages with low cost, high quality medical and dental insurance.
Key Responsibilities
Performs routine audits of in‑house charts upon admission and at least quarterly, to ensure completeness and accuracy. Completes focus audits and PI audits on specific topics as directed by Administrator or Regional Medical Records Director.
Provides notification to staff about deficiencies found in the record and follows up to ensure in‑house records are complete.
Assembles medical records of discharged residents.
Analyzes discharged charts for completeness and follows up with staff and physicians to ensure discharged records are completed.
Processes requests for medical information as directed by the Administrator, Regional Medical Records Director, or corporate Risk Manager (e.g., requests from residents, attorneys, for insurance reimbursement, or in response to a subpoena).
Maintains Release of Information Log for all requests for medical records and copies released for payment, continuity of care, and health‑care operations.
Completes Accounting of Disclosures form according to HIPAA policies and files it in the resident’s chart.
Maintains confidentiality of medical records by ensuring protection of health information.
Monitors physician visits and reports non‑compliance to the DON/Administrator at least monthly.
Purges charts, maintains destruction log, and maintains information for records at off‑site storage facility.
Assigns ICD‑9 CM codes for resident diagnoses; inputs diagnoses and codes into HCS system.
Coordinates physician dictation with outside transcription company.
Files any loose sheets needing attachment to the record.
Maintains supply of forms in department and on nursing units.
Completes discharge/transfer notice when necessary for transfers to hospital or for residents who expire; inputs discharge/transfer data into HCS system and ECS.
Forwards requested records to Carespring Case Manager for managed‑care updates.
Serves as facility contact person to oversee Record Retention and Destruction Policy, working with each department as documents/records are boxed for long‑term storage; signs off on each Record Log to confirm proper completion.
Performs other duties as assigned.
Qualifications
Maintains or is willing to obtain Medical Records Certification.
Detail oriented and can complete tasks on a need‑based schedule.
PointClickCare experience preferred.
Knowledge of Microsoft Word and Excel highly encouraged.
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Pay $14 - $22 depending on certification or credentials. This Medical Records Coordinator will maintain medical records in accordance with state and federal regulations and professional standards. The role requires working every other weekend.
What We Offer
Competitive wages with low cost, high quality medical and dental insurance.
Key Responsibilities
Performs routine audits of in‑house charts upon admission and at least quarterly, to ensure completeness and accuracy. Completes focus audits and PI audits on specific topics as directed by Administrator or Regional Medical Records Director.
Provides notification to staff about deficiencies found in the record and follows up to ensure in‑house records are complete.
Assembles medical records of discharged residents.
Analyzes discharged charts for completeness and follows up with staff and physicians to ensure discharged records are completed.
Processes requests for medical information as directed by the Administrator, Regional Medical Records Director, or corporate Risk Manager (e.g., requests from residents, attorneys, for insurance reimbursement, or in response to a subpoena).
Maintains Release of Information Log for all requests for medical records and copies released for payment, continuity of care, and health‑care operations.
Completes Accounting of Disclosures form according to HIPAA policies and files it in the resident’s chart.
Maintains confidentiality of medical records by ensuring protection of health information.
Monitors physician visits and reports non‑compliance to the DON/Administrator at least monthly.
Purges charts, maintains destruction log, and maintains information for records at off‑site storage facility.
Assigns ICD‑9 CM codes for resident diagnoses; inputs diagnoses and codes into HCS system.
Coordinates physician dictation with outside transcription company.
Files any loose sheets needing attachment to the record.
Maintains supply of forms in department and on nursing units.
Completes discharge/transfer notice when necessary for transfers to hospital or for residents who expire; inputs discharge/transfer data into HCS system and ECS.
Forwards requested records to Carespring Case Manager for managed‑care updates.
Serves as facility contact person to oversee Record Retention and Destruction Policy, working with each department as documents/records are boxed for long‑term storage; signs off on each Record Log to confirm proper completion.
Performs other duties as assigned.
Qualifications
Maintains or is willing to obtain Medical Records Certification.
Detail oriented and can complete tasks on a need‑based schedule.
PointClickCare experience preferred.
Knowledge of Microsoft Word and Excel highly encouraged.
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