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ESSENTIAL DUTIES AND RESPONSIBILITIES:

·    Ensures that all clinical records contain sufficient information to identify the residents; a record of the residents’ assessments; the plan of care and services provided; the results of any pre-admission screenings conducted and required by the State and departmental progress notes.

·    Initiates and participates in the development of facility policies and procedures to ensure that medical records are complete, accurately documented, readily accessible, and systematically organized.

·    Develops and implements record storage and retrieval systems that comply with applicable record retention laws and maintains accessibility of records.

·    Inspects closed records for completeness. Systematically organizes closed medical records for long term storage. Reports delays in completing records to Nursing Home Administrator.

·    Develops and maintains appropriate safeguards against unauthorized access and use of computer-based medical records.

·    Evaluates, through record reviews of open and closed records, compliance with medical record documentation policies. Reports findings to Departments, Nursing Home Administrator and Director of Nursing Services.

·    Maintains, updates, and distributes the lists of facility approved abbreviations and definitions.

·    Provides access to all records pertaining to residents (including current medical record) within 24 hours of oral or written request of resident or legal representative. Make photocopies available within five business days of request.

·    Develops and implements safeguards against loss, destruction, unauthorized access, or use of clinical record information including procedures to maintain confidentiality of all information contained in residents' records and to obtain authorized consents to release information. Releasing information without written consent of resident or legal representative only when required by law.

·    Advises Administration, physicians, facility staff on applicable requirements regarding the control, use, and release of clinical information.

·    Advises Administration on ways to safeguard confidentiality of medical records of facility staff.

·    Collects and displays clinical data requested by Administration, facility committees, regulatory agencies, or accrediting bodies.

·    Communicate with Nursing Home Administrator on daily basis to discuss medical records issues. Recommends to Nursing Home Administrator numbers and types of personnel needed to meet facility needs in compliance with state and federal laws and regulations.

·    Hires and retains qualified competent Medical Records Consultant to provide medical records services, conducts interviews, provides regular performance reviews, takes appropriate job actions, reviews job actions taken by subordinates to assure that staff meet qualification and performance standards and can perform all essential functions of the job.

·    Actively participates in the long-term care survey process by instructing staff in matters of conduct and disclosure, always maintaining a presence when the surveyors are on-site and directing the timely collection of information required by the survey team. Demonstrates concern for identified problems and undertakes effective action while survey is in progress if appropriate. Gathers and presents supplemental documentation to avoid potential deficiencies. Collaborate with Nursing,, Home Administrator to develop responses to survey report as needed. Maintains current skills and knowledge through continuing education. Applies information to job responsibilities.

·    Actively Participates in the planning, introduction and ongoing work associated with maintaining the electronic medical records.

·    Maintains survey Department of Health Entrance Manual

·    Knowledge regarding all long-term care insurances and medical assistance processes and facility practices

·    Knowledge of daily census communication and how it pertains to the medical record and billing practices.

·    Daily rounds on all nursing floor units.

·    Assist and support the Admissions department as needed.

·    Maintains daily census.

·    Maintains quality assurance audits and organizes and takes minutes for the monthly Quality Assurance and Performance Key Indicators.

·    Participate in all meetings as required.

·    Participates in Triple Check for Medicare.

·    Maintains the credentials for licensed Physicians and Consultants.