Health Information Specialist

Corona Post Acute•Corona, CA

11h

About The Position

We believe care goes beyond a medical chart. With kindness and integrity as our guide, we strive for excellence in every interaction. Position Summary: Is responsible for maintaining medical records in accordance with federal and state guidelines, as well as with Company's established policies and procedures.

Requirements

1-2 years' health care related experience preferred, previous experience in Skilled Nursing environment desirable
High school diploma or equivalent required
Knowledge of medical terminology preferred
Willing to work beyond normal working hours, weekends, holidays, and/or on other shifts and in other positions, when necessary
Must be able to read, write and speak the English language sufficiently and comprehensibly enough to perform the essential functions of the job
Must be knowledgeable of nursing/medical practices and procedures, and/or terminology, laws, regulations, and the guidelines that pertain to long-term care
Sufficient computer skills including proficiency in Microsoft Office, Outlook, and /or Internet to perform required duties.

Responsibilities

Complies with all company and departmental policies and procedures.
Assists in preparation of medical record for new admission, completing data required to meet Licensing and Certification requirements, and facility policies and procedures.
Assembles new admission registers and indexes and codes diagnoses.
Performs data entry duties for MDS and physician orders as directed.
Performs medical record audits and re-audits as directed and submits to appropriate parties.
Collects charts, assembles them in proper order, and inspects them for completion.
Ensures incomplete records/charts are returned to nursing service for correction.
Maintains a record of authorized information taken from charts/records, i.e., type of information, name of recipient, date, department, etc.
Assures that medical records taken from the department are signed out and signed in upon return to the department.
Abstracts information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
Indexes medical records as directed.
Mails physician telephone orders on daily basis.
Tracks return and notifies supervisor of delinquent physicians.
Prepares reports for physicians as necessary.
Completes medical record thinning and filing on a regular basis.
Files active and inactive records in accordance with established policies.
Retrieves medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.)
Assists in transfer and discharge process as necessary.
Completes Medicare certifications and recertifications.
Assembles discharge records; obtains discharge summary for each discharge record, follows up as indicated.