Resident Health Information Services Coordinator

NewCourtland; Philadelphia (Philadelphia County); On-site; USD 45,000 - 60,000; Full time

Job summary

NewCourtland is seeking a dedicated Medical Records professional based in Philadelphia to ensure the completeness and accuracy of clinical records. The role involves developing record management policies, maintaining confidentiality, and collaborating with the Nursing Home Administrator to address records-related issues.

Ideal candidates will have strong organizational skills, a keen understanding of medical records laws, and the ability to manage personnel effectively. The position is on-site at Germantown Home in Philadelphia, PA.

Qualifications

• Experience with clinical records management and compliance.
• Strong attention to detail and organizational skills.
• Ability to maintain confidentiality of sensitive information.

Responsibilities

• Ensure completeness of clinical records and organize for long-term storage.
• Develop policies for accurate and accessible medical records.
• Communicate daily with Administration about medical records issues.

Job description

Job Category: Medical Records

Requisition Number: DIREC001304

• Full-Time
• On-site

Locations

Germantown Home
6950 Germantown Ave
Philadelphia, PA 19119, USA

Responsibilities

• Ensures that all clinical records contain sufficient information to identify the residents; a record of the residents’ assessments; the plan of care and services provided; the results of any pre-admission screenings conducted and required by the State and departmental progress notes.
• Initiates and participates in the development of facility policies and procedures to ensure that medical records are complete, accurately documented, readily accessible, and systematically organized.
• Develops and implements record storage and retrieval systems that comply with applicable record retention laws and maintains accessibility of records.
• Inspects closed records for completeness. Systematically organizes closed medical records for long‑term storage. Reports delays in completing records to Nursing Home Administrator.
• Develops and maintains appropriate safeguards against unauthorized access and use of computer‑based medical records.
• Evaluates, through record reviews of open and closed records, compliance with medical record documentation policies. Reports findings to Departments, Nursing Home Administrator and Director of Nursing Services.
• Maintains, updates, and distributes the lists of facility approved abbreviations and definitions.
• Provides access to all records pertaining to residents (including current medical record) within 24 hours of oral or written request of resident or legal representative. Makes photocopies available within five business days of request.
• Develops and implements safeguards against loss, destruction, unauthorized access, or use of clinical record information including procedures to maintain confidentiality of all information contained in residents’ records and to obtain authorized consents to release information. Releases information without written consent of resident or legal representative only when required by law.
• Advises Administration, physicians, and facility staff on applicable requirements regarding the control, use, and release of clinical information.
• Advises Administration on ways to safeguard confidentiality of medical records of facility staff.
• Collects and displays clinical data requested by Administration, facility committees, regulatory agencies, or accrediting bodies.
• Communicates with Nursing Home Administrator daily to discuss medical records issues. Recommends to the Administrator numbers and types of personnel needed to meet facility needs in compliance with state and federal laws and regulations.
• Hires and retains qualified competent Medical Records Consultant to provide medical records services, conducts interviews, provides regular performance reviews, takes appropriate job actions, reviews job actions taken by subordinates to assure that staff meet qualification and performance standards and can perform all essential functions of the job.
• Actively participates in the long‑term care survey process by instructing staff in matters of conduct and disclosure, maintaining a presence when the surveyors are on‑site, and directing the timely collection of information required by the survey team. Demonstrates concern for identified problems and undertakes effective action while the survey is in progress if appropriate. Gathers and presents supplemental documentation to avoid potential deficiencies. Collaborates with Nursing Home Administrator to develop responses to the survey report as needed. Maintains current skills and knowledge through continuing education and applies information to job responsibilities.
• Actively participates in the planning, introduction, and ongoing work associated with maintaining the electronic medical records.
• Maintains the Department of Health Entrance Manual for the survey.
• Keen knowledge regarding all long‑term care insurances, medical assistance processes, and facility practices.
• Keen knowledge of daily census communication and how it pertains to medical records and billing practices.
• Conducts daily rounds on all nursing floor units.
• Assists and supports the Admissions department as needed.
• Maintains daily census.
• Maintains quality assurance audits and organizes and takes minutes for the monthly Quality Assurance and Performance Key Indicators.
• Participates in all required meetings.
• Participates in Triple Check for Medicare.
• Maintains the credentials for licensed Physicians and Consultants.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities. This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.