Medical Records Associate
Park View Health Center
Coordinates the medical records system in compliance with state and federal regulations and facility policies and procedures.
- Develops and maintains an organized system of collecting, completing, and storing clinical records. Determines retention or destruction of records as required by federal and state regulations.
- Implements and maintains a system for coding and indexing diagnoses in accordance with the ICD-10-CM Coding system and Medicare/Medicaid reimbursement regulations using nursing home software.
- Performs current chart audits and discharge audits to ensure completeness of medical records and to identify deficiencies in documentation. Reports identified documentation problems to Financial Services Manager. Ensures extraneous material is removed from charts upon discharge.
Additional Essential Duties:
- Develops and enforces medical record policies and procedures to ensure compliance with federal and state regulations.
- Organizes discharge records according to policy and uploads them into the facility’s scanning system.
- Coordinates release of information. Determines the validity of authorization for disclosure of records in order to maintain confidentiality and comply with state and federal regulations.
- Obtains physician certification and recertification to ensure payment for covered post-hospital Medicare residents.
- Retrieves records and information as needed.
- Coordinates Minimum Data Set (MDS) schedules and maintains current monthly Resource Utilization Group (RUG) rate/certified dates report on all Medicare residents. Acts as liason between disciplines in completion process of MDS schedules and care conferences, and communicates dates and times with appropriate family members or guardians.
- Generates various reports from MDS system such as 802 roster matrix and 672 census and condition reports as requested by surveyors.
- Generates monthly or as-needed Quality Measures Reports for various interdisciplinary departments.
- Receives all physician’s notes and analyses for any diagnosis changes and distributes to appropriate neighborhood.
- Performs weekly transmission to Centers for Medicare and Medicaid Services (CMS) for all MDS assessments.
- Maintains archives for discharged and overflow records.
- Maintains ICD-10-CM codes on all residents. Communicates with physcians and other healthcare professionals to clarify diagnosis or obtain additional information.
- Maintains master resident index and obtains discharge diagnosis/cause of death from primary care provider.
- Performs other related duties as may be assigned.
- Reports to Financial Services Manager.
- Works with all disciplines within the facility, local hospitals, insurance companies, medical providers, and families.
Required Education, Experience, Training, and Certification
- Graduation from a Health Information program with certification as a Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT), preferred.
- Three to five years medical records and/or coding experience, preferably in long-term care.
Knowledge, Skills, and Abilities:
- Knowledge of computerized medical records and nursing home software.
- Ability to prioritize duties and to organize work efficiently.
- Ability to establish and maintain effective working relationships with employees, departments and the public.
- Ability to work under minimal supervision and demonstrate independent judgment and critical thinking skills.
- Strong written and verbal communication skills including listening skills.
- Computer skills including Microsoft Office applications and ability to learn and use software.
- Ability to perform most work from a sedentary position.
- Mobility to move between neighborhoods and medical records overflow area.
- Ability to function in situations encountered in a normal office setting.
- Ability to use standard office equipment including telephone, computer, printer, photocopier and scanner.
- Health insurance
- Dental insurance
- Life insurance
- Long term disability
- Deferred Compensation
- Wisconsin Retirement
- Sick Leave