Requisition #: 21-928
Location: Boerne, TX 78006
Category: Family Services
Service Line: Administrative
Job Description Summary
Responsible for all aspects of maintaining and protecting organization's clinical records. Works with Clinical
Leadership to ensure key elements of the medical record are completed in a timely manner. Maintains tracking
reports of all outstanding documentation and action taken. Routinely performs audits of clinical documentation to
assess compliance with documentation requirements. Reports status of outstanding documentation to leadership
on a routine basis. Routinely reports documentation audit findings to the Education and Compliance Department
and agency leadership as part of the agency's performance improvement program.
Essential Job Functions/Responsibilities
1. Ensures clinical records are maintained in compliance with policies and procedures, following state, federal
and ACHC regulations.
2. Demonstrates exceptional service to patients, families, referral sources, co-workers and other customers.
Assists team members as needed to ensure that this level of service is consistently provided.
3. Protects all clinical records through the adherence to control procedures for all open and closed records.
4. Protects the confidentiality of patient and organization information through effective controls and direct
supervision of clinical records.
5. Forwards copies of clinical records to authorized users according to policy.
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6. On a routine basis, completes an administrative record audit of clinical notes and forwards audit findings tothe Education & Compliance Department and Agency leadership in a timely manner.
7. Monitors missing/incomplete documentation including unsigned physician orders, plans of care and face toface documentation. Works to obtain all missing documentation/signatures as quickly as possible. Escalatesefforts to obtain missing documentation based on length of time outstanding. Keeps agency leadership informed ofdelinquent documentation and actions taken.
8. Attends Interdisciplinary Group meetings and documents IDG findings in the medical record.
9. May be responsible for conducting orientation activities for new employees.
The above statements are intended to be a representative summary of the major duties and responsibilitiesperformed by incumbents of this job. The incumbents may be requested to perform job-related tasks other thanthose stated in this description.
Two or more years of medical records or hospice experience required. Must demonstrate working knowledge of medical terminology, be computer literate with average word processing software skills and be able to type aminimum of 45 wpm. Previous hospice experience preferred. Prior experience with an electronic clinical documentation system preferred. Knowledge of corporate business management, governmental regulations and ACHC standards preferred. An Accredited Records Technician Degree, or LVN/LPN license preferred. Maintains acurrent CPR certification. Must be a licensed driver with an automobile that is insured in accordance with stateand/or organization requirements and is in good working order. Demonstrates excellent observation, problemsolving, verbal and written communications; skills per competency checklist. Shows ability to organize and prioritizeworkload independently. Works indoors in patients' homes. May be required to work in undesirable areas. Possibility of strains due to moving patients.
Continuing Education Requirements: Organization personnel are expected to participate in appropriatecontinuing education as may be requested and/or required by their immediate supervisor. This position requires aminimum of 8 education hours. In addition, organization personnel are expected to accept personal responsibilityfor other educational activities to enhance job related skills and abilities. All personnel must attend mandatoryeducational programs.
ENVIRONMENTAL AND WORKING CONDITIONS
Environmental Conditions: May be exposed to extremes of heat and cold in all weather conditions. Maybe required to drive in various weather conditions on roads in varying degrees of repair.
Working Conditions: May have to manage a number of projects at one time, and may be interruptedfrequently to meet needs and requests. The office environment has a quiet to moderate noise level. Worker may
find the environment to be busy and will need excellent organizational, time management and attention to detailskills to complete the required tasks.
OSHA exposure category
: Category I Position includes tasks that involve exposure to blood, bodyfluids, tissues.
Required Personnel Protective
Equipment: As required by working conditions.
This job description is not intended to be all-inclusive and does not constitute a written or implied contract ofemployment. The employee will be expected to perform other reasonably related duties as assigned by theirimmediate supervisor and/or other management personnel.
The employee will participate and adhere to ALL guidelines contained in the company's complianceprogram.