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MEDICAL RECORDS ASSISTANT (REGISTERED NURSE / RN)
Life Care Center of Merrimack ValleyMA, United States
3 days ago
Job type
Full-time
Job description
Live the Mission
Position Summary
The Medical Records Assistant (RN) assists with patients' clinical records, including coding, auditing, record management, entering physician orders in EHR, clarification and transcription of physician's orders, and monthly verification of MARs / TARs in accordance with all applicable laws, regulations, and Life Care standards.
Education, Experience, and Licensure Requirements
Nursing diploma (associate's or bachelor's degree in nursing)
Currently licensed / registered in applicable State. Must maintain an active Registered Nurse (RN) license in good standing throughout employment
Prior medical records experience preferred
Specific Job Requirements
Demonstrate knowledge of State and Federal legal requirements relating to documentation, confidentiality, and legal issues pertaining to health information
Effectively communicate with physicians, nursing staff, and allied health personnel
Demonstrate efficient usage of complex computer software systems
Expert knowledge in field of practice
Make independent decisions when circumstances warrant such action
Knowledgeable of practices and procedures as well as the laws, regulations, and guidelines governing functions in the post acute care facility
Implement and interpret the programs, goals, objectives, policies, and procedures of the department
Perform proficiently in all competency areas including but not limited to : patient rights, and safety and sanitation
Maintains professional working relationships with all associates, vendors, etc
Maintains confidentiality of all proprietary and / or confidential information
Understand and follow company policies including harassment and compliance procedures
Displays integrity and professionalism by adhering to Life Care's Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training
Essential Functions
Accurately audit and complete ongoing reviews of all patients' clinical records to ensure documentation and performance compliance
Accurately maintain current, overflow, and discharged record filing system
Understand and apply LTC payment systems, including Medicare
Apply the use of ICD 10 CM coding
Enter physician orders in EHR
Contact physician and clarify documents and transcribe orders correctly and efficiently
Verify accuracy of monthly MAR / TAR prior to end of month reconciliation
Understanding of HIPAA requirements
Exhibit excellent customer service and a positive attitude towards patients
Assist in the evacuation of patients
Demonstrate dependable, regular attendance
Concentrate and use reasoning skills and good judgment
Communicate and function productively on an interdisciplinary team
Sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
Read, write, speak, and understand the English language