Job Title: Medical Records Clerk

Department: Medical Records

Reports to: Director of Nursing

Hacienda Oaks Nursing and Rehab is hiring a talented Medical Records Clerk to our amazing team!

Shift: 8am-5pm

SUMMARY: The primary purpose of the position is to ensure the highest quality and cleanliness of resident care available, support staff and establish a positive reputation in the community while delivering on the Eduro HealthCare Values of wellness, compassion, customer experience and company results. This position is responsible for maintaining medical records and coordinating medical records assistants.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

Adherence to Policies

· Must show courtesy and respect to other employees, residents, family members, visitors, government agencies, the public, etc.

· Abide by Eduro HealthCare’s drug and alcohol policy.

· Maintain good personal hygiene and dress and groom appropriately.

• Report on time as scheduled and follow all company policies and procedures.
• Attend staff meetings and in-service sessions.
• Become thoroughly familiar with emergency procedures.
• Must be able to perform duties in a timely fashion, and within the prescribed sequences and schedules.

· Must be cooperative with other departments and be courteous and respectful in always dealing with them.

· Participate in and respond professionally to surveys (inspections) conducted by government agencies.

MEDICAL RECORDS DUTIES include

· Monitoring the resident charts to ensure that all entries are complete and made in a timely manner if the resident resides in the care center.

· This includes keeping a log of Physician's visits, physician telephone orders, therapy reports, and other documents sent for signature.

· Each open resident's chart should be audited at least monthly for deficiencies; a record of such audits should be kept and address any possible medical record problems.

· Each open chart is kept in a neat and orderly manner. This may necessitate removing from the chart, documents non-essential to routine daily care.

· It is the medical records clerk's responsibility to thin charts according to the care center's policy and to keep overflow charts in secure files accessible only to authorized personnel.

· Maintains privacy and confidentiality of all medical records by ensuring that no information is released without proper written authorization.

· Ensures all documents requiring signature are mailed to the appropriate offices daily.

· Files all necessary documents in the residents' record as they are returned from the physician's office. The medical records supervisor should be notified if the mailed documents have not been returned after 14 days (about 2 weeks).

· Completes the following audits:

o Full chart audit daily

• CNA weekly audit
• Diabetic audit two times a month

· Maintains sufficient stock of resident care forms and ensures that both nursing stations are always supplied.

· Files all overflow filing weekly.

· Ensures a supply of admission charts and packets are always available.

· Run errands for the medical records department, as necessary.

Patient Care

· Be personally involved with all aspects of resident care to the extent necessary to assess its quality.

· Respect all resident rights, including the confidentiality of resident care information.

· Report immediately to the proper legal authorities if you have reason to believe a resident has been physically, emotionally, or sexually abused, or been a victim of theft of their private property.

· Create and maintain an atmosphere of warmth, cheerfulness, enthusiasm, and love, giving the resident the quality of service, you would want to receive personally. Reflect the four core values of Eduro HealthCare.

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements listed 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.

Education and Experience

· Sufficient knowledge and experience in long-term care

· High School Diploma

· Previous experience as a Medical Records Clerk and experience in working with geriatric residents is preferred and may be required.

Language Skills

· Must be able to read, write, speak, and understand English sufficiently to perform required duties.

· Must be able to follow verbal and written instructions in English.

• Bi-lingual skills welcome

Certificates, Licenses, Registrations

• Completion of orientation required by company policy.

· Health screening and TB test (if required) within two weeks of employment.

· Mandatory drug test within 90 days (about 3 months) of hire.

· Must be free of criminal activity proven by a criminal background check.

· Become familiar with and comply to all local, state, and federal regulations relating to the job.

· Show within three (3) days of hire satisfactory evidence of identity and eligibility for employment.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. The employee must be able to perform the essential job functions without posing a direct threat to residents, self, or others.

· Frequently move about the facility, transporting equipment and supplies upwards of 50 pounds.

· Must be able to rapidly assist in the evacuation of all residents from the building in case of emergency.

Equipment

Must be able to operate the following equipment: computer equipment and software, all office equipment (stamp machine, copy machine, and other business machines, etc.), telephone, fire alarm.

Work Environment

· May be asked to work beyond normal working hours and must have flexibility and willingness to work holidays, etc.

· Must work in an office and other areas of the facility as needed.

· Is subject to illness, diseases, and other health conditions present in the facility.

· Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

Eduro Healthcare provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible schedule
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Beeville, TX 78102: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Medical records: 1 year (Required)
• Long term care: 1 year (Preferred)

Work Location: One location

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