The purpose of the Medical Records Nurse position is to act as a "gate-keeper" of the electronic medical record system. Region: Southern Indiana
This position audits and maintains the electronic chart for accuracy and compliance according to state and federal regulations.
The results of daily, weekly and monthly audits will be corrected, reviewed and communicated with the nursing department of each facility.
Medical records will follow each audit until all corrections have been completed.
Medical Records is to provide EMR support and guidance to each facility assigned.
They are to serve the facility in whatever the specific need may be.
SITE VISITS AND TRAVEL IS REQUIRED.
EDUCATION, QUALIFICATIONS, CREDENTIALS: Licensed nurse within the State of Indiana; 1-3 years' of clinical management experience in medical records or in an unit manager type of role.
RESPONSIBLE TO: Lead EMR Nurse
ESSENTIAL FUNCTIONS: The employee must be able to perform each essential function effectively to be successful in this position.
Maintains the electronic medical records system through assigned daily, weekly, and monthly audits.
Audits and corrects prior day's activity through specific reports. This information is then provided to the clinical nursing team at each community.
Audits discharge and admission charts specific to the Medical Record role.
Monitors the Medical Records Clerk's compliance with physician visits and unsigned orders. Offers assistance and guidance as needed.
Performs routine focus audits for flu/pneumo, Code Status, physician visits, PPDs, etc. An established schedule for these focus audits is to be maintained. Results of these ongoing audits are to be provided to the Director of Nursing on a routine basis.
Monitors and maintains the fax status log on a daily basis.
Monitors and maintains pharmacy fill reviews on a daily basis.
Enters a monthly level of care order for each resident at assigned communities. A schedule for entering level of care orders is to be maintained.
Monitors labs daily. Ensures labs are drawn and MD/family notified. A schedule for lab monitoring is to be maintained.
Audit resident face sheets on an ongoing basis to verify accuracy.
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What is in it for you?
Innovative Training Programs
Group medical/dental/ vision/life insurance/flexible spending accounts.
401(k) Retirement Plan
Ivy Tech education opportunities
Career Advancement Opportunities
Cell Phone Discount
And much more!
Cardon & Associates