Job Description

Job Description

Job Description

Description:

Responsible for establishing and maintaining resident medical records in accordance with Cascadia policies and state and federal regulations.

Note: All employees of Cascadia Healthcare are required to submit and be cleared to work in the facility per each 

state’s specific background check requirements prior to contact with patients/residents.

Essential Functions

• Provides training, direction and guidance for the medical records staff.
• Ensures medical records are complete, with coordination of electronic function & scanning of hard copy records.
• Audit medical records as directed.
• Data entry into the electronic medical record as directed.
• Compiles statistical data such as admission, discharges & deaths.
• Coordinates to ensure timely MD visit, documentation & signing of orders.
• Closes medical records as directed.
• Restricts access to resident medical records to those staff members with a valid requirement.
• Files documents in accordance with established procedures.
• Services as HIPAA resource for facility and maintains HIPAA disclosure log for the facility.
• Participates in Medicare/Managed Care triple check for accuracy in billing.
• Maintains, retains and archives files in accordance with Cascadia policy and State and Federal regulations.
• Participates in the hiring, disciplining and evaluation of medical records employees.
• Prepares work schedules and maintains adequate staffing.
• Ensures punctuality and regular attendance for assigned shifts.

Other Functions

• Performs other tasks as assigned.
• Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct, its policies and procedures, applicable federal and state laws, and applicable professional standards.

Knowledge/Skills/Abilities

• Knowledge of medical terminology.
• Ability to be accurate, concise and detail-oriented.
• Ability to communicate effectively with residents and their family members, and at all levels of the organization.
• Strong knowledge of HIPAA and privacy regulations.
• Skilled in directing and motivating the workforce.
• Computer proficiency required.
• Proficiency with PCC preferred.

Education

• High school diploma or equivalent required.
• Associate or Bachelor’s degree in Health Information Management, or similar degree, preferred. 

Licenses/Certification

• None.

Experience

• Six months experience in a long term care environment preferred.
• Two years’ experience as a Medical Records Clerk or with record keeping responsibility in a health care setting.
• PCC experience preferred.

Job Tags

Similar Jobs