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Medical Records Nurse

Company: Briarcliff Health and Rehabilitation
Location: South Bend
Posted on: January 25, 2023

Job Description:

Briarcliff Health and Rehabilitation - Briarcliff Health & Rehabilitation Center is looking to hire a Medical Records Nurse.
> The Medical Records Nurse maintains resident records/charts. You will organize and maintain facility medical records system in compliance with facility, state and federal regulations.
> > To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required.
1. Nurse (LPN) with a current license.
2. Caring person with a desire to work with the frail and elderly.
3. Practical knowledge of medical terminology and record keeping preferred.
4. Ability to read and understand procedures used for work assignments.
5. Ability to maintain confidentiality related to residents' medical condition.
6. Ability to prioritize duties and be detailed orientated.
7. Ability to understand and follow work assignments and have knowledge of coding and filing systems.
8. Ability to work as part of a team.
9. Ability to establish and maintain optimum rapport with residents, family members and regulatory agencies.
10. Ability to utilize computers and other electronic devices for tasks such as timekeeping, in-servicing and documentation.
> > To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
a. Maintains accurate order of open charts;
b. Assist in collecting discharged resident records and assemble and analyze medical records;
c. Ensures that all Admission Orders are signed by the attending physician in a timely manner;
d. Open new records for admission in proper order with patient identification data on each sheet.
e. Collect thinned records and assemble, analyze and evaluate.
f. Understand state and federal laws and regulations and facility policies regarding medical records.
g. Assists in ensuring all Medicare Certifications and Re-certifications are signed in a timely manner;
h. Maintain a documented, organized system, which is readily accessible by other authorized professionals.
i. Ensure that all reports are completed within established time frames.
j. Assists nursing staff with monthly editing and perform chart audits.
k. Maintains forms/office supplies inventory under the direction of the Director of Nursing or designee;
l. Answers telephone inquiries and may answer correspondence;
m. Performs miscellaneous duties pertaining to medical records;
n. Writes, types and distributes advance notices for admissions, readmissions, room changes, any status changes, discharges, etc. to appropriate staff;
o. Obtains all appropriate departmental and physicians' signature on discharge charts within 30 day of discharge;
p. Assists Director of Nursing Services with any other duties that may be assigned.

Keywords: Briarcliff Health and Rehabilitation, South Bend , Medical Records Nurse, Healthcare , South Bend, Indiana

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