Assists the clinical department in recordkeeping, chart audits, statistical reports, and typing. Responsible for entering data such as new admits, changes in level of care, discharges, contact visits, physician orders, resolving orders, and entering physician signature dates and face-to-face completion dates into the electronic medical record. Orders supplies and performs other support tasks as required.
Maintains and updates patient files in EMR. Completes chart admission audits and communicates issues to the Clinical Director. Inputs changes relating to clinical status, insurance, level of care, staff assignment, or discharge into current software. Scans and files clinical data, hand-signed orders, and consents into patient records. Ensures timely opening of plan of care/comprehensive assessments for documentation prior to team meetings. Tracks certification statements, recertifications, and physician orders, running unresolved order reports weekly.
Maintains patient on-call book. Contacts physicians' offices, hospitals, or nursing facilities for current admission and chart information. Assists with providing information for annual reports and other patient data. Receives and compares visit logs to contact visit reports weekly. May assist with tracking and ordering durable medical equipment (DME) and medical supplies. Participates in Quality Assessment and Performance Improvement activities. Responsible for ensuring documentation is present at team meetings, maintaining team meeting sign-in sheets, and ensuring attachment of problem lists.
Closes paper clinical/bereavement charts and prepares charts older than 13 months for off-site storage, coordinating with the Clinical Director. Types letters, reports, and other materials as requested. Answers telephone professionally and directs calls appropriately. Interacts with other disciplines as needed. Completes other assigned duties.
Position requires a high school diploma or equivalent, at least one year of medical records experience (preferably home health or similar), positive interpersonal and organizational skills, flexibility, self-direction, and ability to function as a member of an integrated healthcare team.
- High school graduate or equivalent.
- One year of medical records experience, preferably in home health or similar operation.
- Positive interpersonal skills and good organizational skills.
- Flexible, cooperative, and self-directed.
- Ability to function as part of an integrated healthcare team.
Location
Florida, US
Employment Type
Full-time
Experience Level
Entry Level
Remote work allowed
No
Posted
1 month ago