Job Information

North Shore Healthcare Medical Records Director - Full-Time 1st Shift in Menomonee Falls, Wisconsin

Trust, engagement, competence, respect and passion – these are the values under which North Shore Healthcare operates every day. Our dedicated team of professionals strive to deliver quality care to our residents and their families. We are one of the leading employers and providers of post-acute care in the Midwest and we are seeking exceptional individuals to join our team. If you value being a leader, working in a progressive environment and having opportunities to grow in your career, North Shore Healthcare is the Right Choice for you. Summary of position: Responsible and accountable for resident health care records. Maintains resident data and management of the Medical Records department as defined by State Nurse Practice Act. As appropriate, complies with JCAHO standards. Essential Functions: easonable accommodations may be made to enable individuals with disabilities to perform the essential functions. * Maintain and secure all written and electronic medical records within the center medical records department/area * Ensures information within records is complete, accurate * Provides records to authorized personnel, following appropriate protocols * Assign diagnostic code to newly identified resident conditions/diagnoses for reimbursement, MDS completion and internal needs * Evaluate requests for information to assure releases are made only in compliance with federal and state laws * Retain and destroy records per policy and in accordance with Federal and State laws * Retrieve records for use by administrative or interdisciplinary personnel for resident care, quality improvement, incident tracking and investigation and other authorized purposes * Enter phone orders, laboratory and X-ray reports daily * Process/monitor physician telephone orders * Maintain and track file authorization for release of information * Audit Open Charts * Ongoing checks for MDS completion, summaries, weights, vitals, physician order signatures, etc. providing results to nursing leadership and ED. * Evaluate for missing documentation, charting or signatures * Check flow sheets for completion * Check charts due for physician visits, annual physicals * Discharge Record preparation/maintenance * Assemble charts, assure form completions with necessary dates, signatures, et ? Gather forms from all departments as needed * Assign diagnostic codes to final diagnoses at discharge * Notify outside providers of deficient records February 2018 * Retrieve requested records * Collect/prepare statistical data as requested * Research and keeps abreast of new regulations by Medicare, Medicaid and insurance companies * As directed by center leaders, provides information to employees * Maintain forms at the nursing stations * Supervises department personnel (i.e., medical record coordinator, Unit Clerk) * Employment activities to include, hiring, training, performance management * Research and keeps abreast of new regulations by Medicare, Medicaid and insurance companies * As directed by center leaders, provides information to employees * May manage the budget for the department * Complies with laws and regulations applicable to position and act in accordance with Center’s Compliance Program * Attends and participates in in-service training, performance improvement (“PI”) committees and other meetings as scheduled and directed Work Environment/Physical Requirements: The responsibilities of this position involve significant physical activities including standing, lifting (up to 50 pounds unassisted), bending, stooping, pushing, pulling and twisting. All employees of nursing homes may be required to provide lifting and transfer assistance to residents. Lifting and/or transferring some residents will require use of a lifting device and /or assistance of other staff. Required Education and Experience: * Bachelor’s degree in Health Information Management (accredited by Commission on the Accreditation for Health Informatics and information Management Education (CAHIIM) or equivalent combination of experience and education * Minimum one-year experience * Computer proficiency with Microsoft products Preferred Education and Experience: * Experience in a fast-paced environment * Post-acute care or health care experience preferred Skills, Knowledge and Abilities: Knowledge of medical terminology.: * Ability to follow directions and work independently with minimal supervision. * Ability to relate positively, effectively, and appropriately with residents, families, community members, volunteers and other center staff. * Meets all health requirements imposed by law. * Able to read, write, speak and understand English. * Demonstrates basic computer knowledge and ability with an aptitude to learn company applications. Benefits: We offer a comprehensive benefit packages which includes: * Health insurance for full-time employees starting the first of the month following 30 days of employment * Dental and vision insurance for full and part-time staff * 401(K) Program for full and part-time staff * 6 paid holidays plus one floating holiday for full-time staff * Company paid life insurance for full-time staff * Voluntary life and disability insurance for full-time staff * Paid Time Off Our mission is to establish a culture that reinforces the values necessary to be the premier health services provider and employer in each of the communities we serve. We understand that choosing where you want to go in your career is a big decision. We would like the opportunity to show you that North Shore Healthcare is the Right Choice for you.