Medical Records Coordinator/Unit Manager in Terre Haute, Indiana at Westminster Village Terre Haute

Job description:

TITLE: Medical Records Coordinator/Unit Manager

EXEMPT STATUS: Exempt

REPORTS TO: Director of Nursing

GENERAL SUMMARY:

The Unit Manager/Medical Records Coordinator is responsible for the overall nursing care/service on his/her unit, including the accurate and timely administration of medications, treatments, documentation, and emergency calls, as indicated. Also responsible for entering, transcribing, recording, storing, or maintaining information in written or electronic/magnetic form of the Health Center medical records. Performs day-to-day administrative tasks such as maintaining information files and processing paperwork. Compiles, codes, categorizing, calculating, tabulating, auditing, or verifying information or data of the Health Center medical records.

PRINCIPLE DUTIES:

Essential Job Duties:

1. Supervises direct care of residents and nursing personnel on his/her unit.

2. Ensure that team shift report is preformed at the beginning of each shift.

3. Ensures quality of care and compliance with State Regulations for all staff.

4. Act as a resource person for staff, family, and clinical concerns and walk in and phoned in referrals.

5. Performs daily compliance rounds as assigned.

6. Administers direct care as necessary.

7. Gives and receives shift reports.

8. Rounds twice a shift to assure proper care is rendered in a safe and clean environment.

9. Keeps physicians and families aware of changes in resident’s condition.

10. Assists in developing comprehensive care plans.

11. Participate in on call rotation.

12. Supervises Central Supply clerk.

13. Maintains complete and accurate current and discharged residents’ medical records according to State and Federal guidelines.

14. Sends correspondence to Providers relating to requested medical record information.

15. Observing, receiving, and otherwise obtaining information from all relevant sources in relation to Health Center medical records.

16. Provides information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.

17. Maintains confidentiality of medical data.

Other Duties:

1. Maintains the self-respect, personal dignity, and physical safety of each resident.

2. Maintains accurate documentation of all care rendered.

3. Interfaces with other disciplines to assure continuity of care and services.

4. Encourages restorative care in order to obtain maximum resident independence.

5. Participates in family/resident counseling as necessary.

6. Assists in monthly QAPI studies.

7. Contribute input for staff evaluations and any necessary staff disciplinary action.

8. Assists in maintaining a high level of customer satisfaction for our residents and guests.

9. Responds to emergency calls as necessary.

10. Attends in-service training and education sessions, as assigned.

10. Assures proper functioning of equipment and adequate supplies.

11. All other duties and responsibilities as assigned.

HOSPITALITY FOCUS:The Westminster Village fully embraces a culture of hospitality. To that end, we include the following hospitality promises as a guide for our interpersonal interactions with residents, co-workers, and guests:1. We greet residents, employees and guests warmly, by name and with a smile.2. We treat everyone with courteous respect.3. We strive to anticipate resident, employee and guest needs and act accordingly.4. We listen and respond enthusiastically in a timely manner.5. We hold ourselves and one another accountable.6. We embrace and value our differences.7. We make residents, employees and guests feel important.8. We ask “Is there anything else I can do for you?”9. We maintain high levels of professionalism, both in conduct and appearance, at all times.10. We pay attention to details.WELLNESS FOCUS:The Westminster Village employees are expected to promote a healthy community culture for all residents and employees. This is a whole-person approach to health and wellness which includes eight dimensions of wellness: Emotional, Environmental, Health Services, Intellectual, Physical, Social, Spiritual and Vocational. Through these efforts we can ensure and exceed residents’ wellness needs relating to their mind, body and soul, which may also have a positive effect on the employees, as a result.EEOC EmployerBenefits:

• 401(k)
• Dental insurance
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person

QUALIFICATIONS:

1. RN/LPN currently licensed in the State of Indiana.

2. Current CPR certification

3. Ability to communicate effectively in English and perform simple arithmetic.

4. Word processing experience and knowledge of medical terminology required.

5. Requires good judgment to plan, perform and set-up sequences within standard procedures. Requires analysis of facts and information to take action following established guidelines.

6. One year experience in health care setting preferably in long term care.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS:

Frequent standing, stooping, bending, stretching, squatting; must be able to stand/walk for up to 70% of the work day. Must be able to lift and carry up to 20 lbs. frequently and 50 lbs. occasionally. May be exposed to blood and body fluids which may contain HIV and/or HBV; must be able to transport residents via wheelchair, gerichair or shower chair, pushing up to

250 lbs. unassisted. Must be able to transfer, lift, turn and position a resident weighing up to 150 lbs. unassisted, or with the assistance of one for a resident weighing over 150 lbs. May be subjected to offensive odors and combative behaviors.