Med Records Tech

Magnolia Manor; Groves (TX); On-site; USD 36,000 - 54,000; Full time

Benefits offered by this job

401K with match

CEU reimbursement

Vacation and holidays

Medical insurance

Dental insurance

Supplemental insurance

Job summary

Magnolia Manor in Texas is seeking a Medical Records Technician to establish and maintain organized medical records in compliance with OBRA guidelines and state standards. This role supports the nursing department administratively and clinically as needed.

Responsibilities include managing EMR documentation, audits, and releases of information, maintaining record inventory, and ensuring timely e-signatures.

Qualifications

• Type at 40+ wpm accurately and efficiently.
• Strong computer literacy and EMR workflow understanding.
• Fluent reading, writing and speaking English for clinical communications.

Responsibilities

• Maintain established medical record files according to policy and state standards.
• Scan and file patient information into the EMR system.
• Audit records and ensure timely e-signatures and compliance with regulations.

Skills

Typing 40 wpm

Computer literacy

English language proficiency

Education

Registered Health Information Technician

High school graduate

Job description

Job SummaryThe overall purpose of the Medical Records Technician position is to establish and maintain organized medical records and files, according to acceptable policies and procedures that include OBRA guidelines and Texas, NM, LA state standards. At times, this position may provide clinical and administrative support to the nursing department.Qualifications:Registered Health Information Technician or high school graduate (or equivalent)Accurate typing skills of 40 wpm or more are neededMinimum of one-year experience in medical records within a long-term care setting is preferredComputer literacy is mandatoryAbility to read, speak, and write the English languageEssential Functions:Maintains established medical record files; scans in documentation in the EMR accordance with company policies and procedures as well as federal and state-specific regulations.Scans (Files) Patient information in individual charts accurately.Establishes and maintains inventory of forms, and supplies for Nurses station. Prepares spend-down sheets and submits to Executive Director.Prepares any correspondence for medical records.May enter physicians orders into the clinical software system when applicable.May enter weights into the clinical software system.Keeps a soft file of weights in medical record office.Submits interim orders and physicians order sheets monthly to physicians for signature and ensures timely e-signature.Participates in Monthly Quality Assurance Meeting.Audits medical records per company policy and procedure and notifies all physicians of compliance issues with H&Ps and Progress Notes.Submits daily, weekly, and monthly audits of charts to Unit Managers, Director of nurses & appropriate department heads for review, correction or closing of forms.Copies all requested documents and keeps requests in a folder clearly visible in medical records. Records request may be discarded 1 year from request being filled.Maintains a log of all medical records requests for quick reference.Ensures all discharge records are closed as specified in Medical Records Manual.Ensures the completion of discharge summary (IDT) and all documents under assessments.Works with legal counsel to prepare records for release of information.Reviews Cantex Continuing Health Care, LLCs Clinical Policies and Procedures for Abuse prevention and knows the employees responsibility to enforce it.Attends weekly in-services, understands, and complies with Patient Care Management Systems.Perform other duties and tasks as assigned.We are an Equal opportunity employer; We offer an excellent benefit plan to include 401K with match, CEU reimbursement, vacation, sick, holidays, medical, dental, and supplemental insurance Plans as well as a Highly competitive compensation package.