Medical Records Clerk - Home Care jobs in Pennsylvania

Cliveden Nursing and Rehabilitation Center is a 180-bed skilled nursing facility offering short term rehabilitation and long-term care services. Our staff is committed to providing excellent care and services in a friendly, resident focused, home-like environment.

The Medial Records Clerk assumes authority, responsibility and accountability for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards and state and federal laws and regulations for long term care facilities. Establishes and implements policies to ensure that records are complete, accurately documented, readily accessible and systematically organized. Collaborates with Nursing Home Administrator to allocate department resources in an efficient and economic manner to achieve department objectives.

Essential duties and responsibilities include but are not limited to:

·         Ensures that all clinical records contain sufficient information to identify the resident; a record of the resident’s 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.

·         Is responsible for all diagnostic disease and treatment coding for all admissions and subsequent treatment as reviewed by and communicated to Medical Records to ensure consistency within the clinical record.

·         Conducts, at a minimum, quarterly disease code reviews in conjunction with the Interdisciplinary Care Conference Team. Inputs any changes into RMA and ensures an updated copy is on the resident record.

·         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 system that complies with applicable record retention laws and maintains accessibility of records.

·         Inspects closed records for completeness. Systematically organizes closed medical records for qualitative/quantitative analysis and long-term storage. Reports delays in completing records to Nursing Home Administrator. Files completed discharge health record in appropriate area.

·         Evaluates, through record reviews of open and closed records, compliance with medical record documentation policies. Maintains audit system according to policy and procedures to assure completeness, accuracy and internal consistency. Obtain complete and accurate records within established time frames. Reports findings to Nursing Home Administrator and Director of Nursing Services.

·         Attends meetings as requested by the Administrator.

Applicant requirements include:

·         CDC COVID-19 vaccination card showing fully vaccinated

·         Associates or Bachelor’s degree from an accredited college or university

·         Current certification as a Registered Health Information Technician or Registered Health Information Administrator

·         Proficiency using Health Information Management systems as well as Microsoft Office applications

·         One-year experience as a medical records practitioner, preferably in a long-term care facility

The company offers a generous annual salary and signing bonus as well as:

·         Health, dental and vision benefits

·         Voluntary benefits such as short-term disability, life insurance, etc.

·         Holiday, sick and vacation paid time off.

·         401(k)

We're an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.