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Description
Compile and set up residents’ medical records and enter data into software system.
Collect information from nursing staff, physicians, and other sources and update data in software and hard copy needed.
Monitor and audit records for completeness and accuracy in accordance with company policies and state regulations.
Provide resident information to the business office.
May participate in completion of MDS’s, UR meetings and any other related functions.
Process transfer or discharge record and discharge auditing.
Maintain appropriate records on former residents, storage per company policy.
Assist in coordinating Nursing Department activities to include administrative support and audits and education.
Run errands that may include travel to hospitals and doctor offices for documentation needing signatures.
Daily auditing of Medicare documentation in support of Nursing and Therapy RUG scores as well as changes in condition for all records.
QI and IC functions as time permits and as directed.
Nursing, physician services, and other clinical services and medical records audits.
Utilization Review Committee meeting member responsibilities.
Resolve/clarify codes and diagnoses with conflicting, missing or unclear information and consult with doctors or others to get
information.
Prepare statistical reports or narrative reports for physician, facility, company, or state agency (vital records, death report, infection reporting).
Prepare hard copy of records for use during power failures and emergency situations as per policy.
Compile census, demographic or medical data as requested by facility, company, or state/federal agency.
Oversee appropriate use and documentation in software and provide audits/education as needed or directed.
Medical chart auditing in support of Medicare Part B services, clinical services such as QI and IC, chart audits for nursing and physician services.
HIPAA Privacy Officer responsible for the facility’s HIPAA compliance, in conjunction with the Administrator and HIM, including but
not limited to all regulations, laws, policies and procedures, forms and logs.
Requirements
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Must meet all local health regulations and pass post-employment physical exam if required. 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
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