Job Postings

Job ID MDS-01
Title MDS (Medical Records Specialist)
Department Administration
Job Description:

The purpose of this position is to assess residents' physical and mental function and document data on minimum data set forms completely and accurately; document all additional assessments required completely and accurately; and determine appropriate referrals to other health care professionals; and to use the resident assessment protocols to determine whether to proceed or not proceed.

  • Interview residents, residents' representatives and others with information related to the minimum data set assessment.
  • Collect all data necessary to complete minimum data set forms and related documentation.
  • Coordinate Quality Assurance meetings.
  • Participate and/or conduct interdisciplinary meetings.
  • Review medical records and records related to residents' health status to collect information related to the minimum data set assessment.
  • Enter data into the computer program for minimum data set assessments.
  • Assume accountability and responsibility for accuracy of Minimum Data Set (MDS) assessment information.
  • Every Friday post lab for coming week.
  • Comply with all federal and state regulations when completing the Minimum Data Set assessment.
  • Comply with all facility policies and procedures when completing the Minimum Data Set assessment.
  • Schedule Minimum Data Set assessments to comply with federal and state regulations and facility policy.
  • Receive and file all diagnostic reports promptly and accurately.
  • Electronically transmit Minimum Data Set assessments in compliance with federal and state regulations.
  • Print Minimum Data Set assessments and related reports from the computer program.
  • Coordinate weekly care plan meetings for Director of Nursing.
  • Coordinate scheduling with Director of Nursing to assure compliance with State regs.
  • Conduct and/or participate in interdisciplinary team and rehabilitation conference meetings.
  • Complete reports and assignments accurately and adhere to established time schedules.
  • Maintain confidentiality of resident and facility information.
  • Establish open lines of communication between all nursing personnel.
  • Observe infection control procedures relating to nursing services.
  • Observe Residents' Rights policies at all times.
  • Observe all facility safety policies and procedures.
  • Come to work as scheduled and consistently demonstrate dependability and punctuality.
  • Consistently work cooperatively with administration, nursing service personnel, physicians, community agencies, residents, families and consultants.
  • Come to work in a clean, neat uniform and consistently present a professional appearance.
  • Assume accountability for data contained in the employees' handbook.
  • Perform other duties as directed by the Director of Nursing.
  • Perform all duties assigned in a cooperative, effective, timely and professional manner.
  • Be responsible for the safety of residents under his/her supervision.
  • Orient all new employees (all departments).
  • Complete paperwork for new employees on day of orientation and turn in to Administration.
  • Assist with admission, transfer, and discharge of residents as assigned by the Director of Nursing.
  • Develop monthly calendar of duties for Director of Nursing.
  • Protect all medical record information from loss, defacing or destruction before retention period ends.
  • File medical records promptly and accurately.
  • Retrieve medical records promptly upon request by authorized individuals and agencies.
  • Identify late and incomplete documentation and report to individuals responsible for completion.
  • Identify inaccurate documentation and report to individuals responsible for accuracy and documentation.
  • Audit medical records, as assigned.
  • Collect and accurately process telephone orders daily.
  • Complete identification on forms in residents' medical records.
  • Assemble admission packets.
  • Process admission and discharge records timely and accurately.
  • Complete all information on admission records and place in medical record holder following facility policy and procedure.
  • Assist the Administrator and Director of Nursing to coordinate all required committee and meeting functions.
  • Enter physician orders and other information into the computer timely, accurately and completely.
  • Print forms and reports from the computer program as required.
  • Audit transfer/discharge information for accuracy and completeness.
  • Gather information for Medicare billing and complete by 2nd work day of each month.
  • Order medical supplies and nursing equipment as required by Director of Nursing.
  • Ensure Medicare residents have timely certification/re-certification forms signed by the attending physician.
  • Be responsible for ordering supplies monthly.
  • Maintain supplies in a neat, clean and organized manner.
  • Receive, review and have requisitions approved before ordering.
  • Receive or unload supplies and distribute, stock and/or store in a neat, efficient and safe manner.
  • Report any problems with ordering or obtaining supplies to the Director of Nursing.
  • Provide accurate reports to D.O.N. of the type and amount of supplies received.
  • Must be familiar with Long Term Care state and federal rules and regs
  • Must be knowledgeable in computers (Outlook or Outlook Express, Internet Explorer, Microsoft Office, Microsoft Windows XP)
  • Must be able to lift, stoop, bend, squat, etc. without restrictions
  • Must be familiar with Quality Assurance
  • Must be familiar with Infection Control
  • High school diploma
  • Must have current CMA license
    Continuing Education:
  • As required by state and facility, including seminars.
  • Monday - Friday
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