Responsibilities The Medical Record Clerk/Coordinator works with the Director of Nursing to assure the following responsibilities are accomplished. This list is only partial and should not be interpreted as a comprehensive inventory of all duties, tasks and responsibilities.
1. Should be knowledgeable about release of information and releasing information according to requests and State and Federal guidelines.
2. Prepares copies of records when required with assistance of administrator.
3. Destroys clinical records according to facility policy and procedure and State Statue.
4. Maintains filing system in an organized manner for both active and discharged records.
5. Promptly assembles discharge residents for closing in proper Order of Final Filing.
6. Performs audits to assure completeness of discharge records.
7. When necessary, prepares the Discharge Summary, outlines the data and obtains all final/transfer/death diagnoses.
8. Assigns the necessary codes for diagnoses.
9. Prepares and maintains pre-admission packets and chart "set-ups" for new admissions. 10. Assembles chart in proper order of Active Chart Order.
11. Prepares photo for MARs.
12. Inputs data into computer on all admissions.
13. Verifies timely physician visits for all residents as required.
14. Verifies Medicare residents certifications signed timely.
15. Inputs or audits physician orders daily.
16. Prints monthly physician's orders.
17. Thins active records per retention guidelines.
18. Maintains lab tracking.
19. Organizes paper forms at stations for prompt retrieval.
20. Other duties as assigned by supervisor.
21. Attends and participates in facility meetings.
22. Participates in Quality Assessment and Improvement Program
23. Participates in Quality Assessment Performance Improvement Program
24. Reports immediately to supervisor and administrator situations involving abuse, neglect, or suspicion of a crime.
25. Adheres to the Code of Conduct, Compliance Program, HIPPA Standard, and Computer Usage Agreement
Requirements:
- Valid nursing license in Louisiana
- Bachelor's degree in Nursing
- Proficient in medical terminology, including knowledge of common medical conditions and procedures
- Familiarity with electronic medical records systems
- Strong communication and interpersonal skills
- Ability to work effectively in a fast-paced environment with a diverse patient population
- Excellent problem-solving and critical thinking abilities
- Ability to prioritize tasks and manage time effectively
Benefits:
- Competitive salary based on experience and qualifications
- Comprehensive health insurance coverage
- Retirement savings plan with employer match
- Paid time off and holidays
- Continuing education opportunities for professional development
Job Type: Full-time
Pay: $23.00 - $25.00 per hour
Expected hours: 40 per week
Benefits:
Schedule:
Education:
Ability to Relocate:
Work Location: In person
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