Medical Records / CMA / CNA

Primary Purpose of this Position

The primary purpose of this position is to maintain resident medical records and health information systems in accordance with current federal and state guidelines and established privacy policies and procedures.

Duties and Responsibilities

Administrative Functions

• Respond to requests for medical record information by insurance companies, Medicare, Medicaid, Veterans Administration(VA)or healthcare providers as authorized and in accordance with the Health Insurance Portability and Accountability Act (HIPAA)privacy and security requirements.
• Ensure medical records are properly completed, assembled, coded, signed, indexed, etc., before filing.
• Assure that medical records taken from the department are signed out and signed back in upon return to the department.
• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.
• Audit and review electronic health record (EHR)documentation for accuracy and completion.
• Maintain medical health records in a manner that is consistent with administrative, legal and regulatory requirements and best practices.
• Complete medical record and documentation competencies as directed.
• Audit and thin medical records per facility policy and as directed.
• Coordinate with hospital and admission office regarding proper ICD-10 (International Classification of Diseases-Tenth Revision) coding as acceptable for Patient Driven Payment Model (PDPM)and other reimbursement methodologies.
• Return incomplete records / charts to appropriate departments or personnel for correction.
• Facilitate the transportation, retrieval and delivery of medical records from nursing units, chart racks, therapy or other facility designated locations while safeguarding protected health information (PHI).
• File or input information into resident charts as requested.
• Fulfill authorized medical records releases (hardcopy and electronic) as directed by facility policies in accordance with verified court-ordered request, legal request or as requested by appropriate and lawful means.

Duties and Responsibilities

Equipment and Supply Functions

Replenish administrative supplies in work areas as necessary in accordance with facility budget and established par levels.

Working Conditions

Education

Must possess, as a minimum, a high school diploma or its equivalent.

Experience

Specific Requirements

Physical and Sensory Requirements (with or without the aid of mechanical devices)

Job Position Analysis Information

(1) Risk Exposure to Blood / Body Fluids Column :

A check mark entered into this column indicates the risk potential of your exposure to blood or body fluids. Established procedures identify the appropriate personal protective equipment (PPE) that you should use when performing this task.

(2) Essential Functions Column :

A check mark entered into this column indicates that you may be required to perform this task.

(3) Safety Factors Column :

RM = Repetitive Motion :

A "RM" in this column indicates that it will be necessary for you to perform some functions of this task repeatedly. When such tasks are not performed properly injury can result. Established procedures identify the precautions and / or equipment that should be used.

WL = Minimum Weight Lifting Requirement :

A "WL" in this column indicates that it will be necessary for you to perform functions of this task that require some lifting, moving, pushing or pulling. When such tasks are not performed properly injury can result. Established procedures identify the precautions and / or equipment that should be used when performing this task. Minimumweight lifting requirements that you must perform are located in the "Physical and Sensory Requirements" section of this job description.

SB = Prolonged Sitting, Standing and Bending :

A "SB" in this column indicates that some functions of this task require you to sit, stand or bend for an extended period of time. When such tasks are not performed properly injury can result. Established procedures identify the precautions and / or equipment that should be used when performing this task.