Applications are submitted online until the position is filled and/or the posting is closed. After reviewing this job announcement, please click on the link at the bottom of the page to apply online. A resume is required with the application. Further instructions on submission of documents are available in the online application. A resume may not be substituted for an application.

The incumbent compiles and maintains clinical records of residents in the Regional Centers to document residents’ condition and treatment. Work is performed in accordance with Federal, state, and local guidelines and regulations, HIPPA, that govern long term care facilities, under the direction of the Medical Records Supervisor.

• Reviews clinical records for completeness, and to abstract and code clinical data such as diseases, procedures, and therapies.
• Compiles medical care and census data for statistical reports on types of diseases treated, in response to inquiries from law firms, insurance companies, and government agencies.
• Maintains clinical records filing systems and procedures to facilitate the distribution and use of clinical records throughout the Centers, in accordance with HIPAA requirements. 
• Maintains and utilizes a variety of health record indexes and storage and retrieval systems and verifies accuracy of assigned admissions numbers versus master index for all records.
• Codes diagnosis according to ICD-10-CM for purposes of classification of morbidity and mortality data for statistics, MDS, and UB.
• Assures that confidentiality of clinical records is protected through written consent of the resident or designated agent acting on behalf of the resident, prior to release of information. Notifies administration and follows procedure for subpoenaed records.
• Establishes and maintains purging cycle for clinical records, assuring that records are maintained for a minimum of seven years following a resident’s discharge or death.
• Completes clinical records within 30 days of discharge.
• Performs related duties as assigned or directed by the Medical Records Supervisor.

• Rules, regulations, laws, and guidelines governing the maintenance and release of medical record information, such as HIPAA.

• Establish and maintain effective working relationships with practitioners, managers, supervisors, co-workers, and employees.
• Function independently and to work effectively with residents, their family members, personnel, and support agencies.
• Work with ill, disabled, elderly, and emotionally upset people within a long term care facility.
• Communicate effectively, both orally and in writing.
• Operate a computer to process, store, and retrieve health information.