Job description

Beachside Post Acute is a 110-bed SNF located in Torrance, CA.

Qualifications:

• Experience working in medical records in skilled nursing
• Knowledge of Skilled nursing facility (SNF) medical records regulations
• Knowledge and application skills for ICD-10-CM coding
• Knowledge of PointClickCare (PCC) medical records systems
• Knowledge of medical terminology, anatomy and physiology
• Knowledge of pathophysiology and pharmacology
• Must be authorized to work in the United States

Responsibilities:

• The Medical Records is responsible for the overall management of the Medical Records Department, including the development and implementation of health information policies and procedures
• The HIM Director also acts as a liaison between information services and clinical services departments, ensuring that health information policies and procedures are functioning in accordance with the needs of the facility
• The Medical Records Director is also responsible for educational programs relating to health information, when applicable, for facility staff members, including the facility clinical staff
• SECURITY, CONFIDENTIALITY and RELEASE OF HEALTH INFORMATION: Safeguards the confidentiality of patient records from unauthorized review or release
• Provides oversight for the prompt and appropriate release of information tasks
• Keeps abreast of federal and state law
• Responds to court subpoenas as custodian of medical records and presents records in court when deemed necessary
• HIPAA (Health Insurance Portability and Accountability Act): Works to ensure compliance with HIPAA requirements
• Participates in ongoing activities related to the development, implementation, maintenance of, and adherence to policy covering the privacy of, and access to, patient privacy practices
• CODING: Serves as the coding specialist and/or oversees the assignment of the appropriate ICD-10-CM diagnostic and procedural codes to individual patient information for data retrieval analysis and claims processing
• Queries physicians and/or oversees the query process when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes
• Abides by the standards of ethical coding as set forth by the American Health Information Management Association and adheres to official coding guidelines
• When applicable, serves as a key player in providing oversight in the appropriate assignment of Impairment Groups under the Preferred Payment System (PPS) for Rehabilitation and UDS data submission, as applies to rehab locations
• REPORTING REQUIREMENTS: Timely submits required data to the Center for Medicare and Medicaid Services (CMS)
• CHART AUDITS/COMPLIANCE: Coordinates monthly interdisciplinary record reviews
• Assists in performance improvement activities as recommended by QAPI Committee
• Tracks, trends, monitors, and reports timeliness of physician documentation including the medical record delinquency number as per HIM policy/guideline to the QAPI Committee, MEC, and Governing Board
• DOCUMENTATION AND RECORD COMPLETION: Works with clinical staff, physicians, consultants, nurses, therapists, etc., to ensure documentation is in compliance with hospital, accrediting, and licensing guidelines and provides ongoing education to staff
• Strives to help ensure timely record completion
• Reports deficiencies and record completion compliance to appropriate supervisors

Responsible for the monthly calculation of the record completion rate to the Administrator

Job Type: Full-time

Pay: $28.00 - $30.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Torrance, CA 90505: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Medical records: 1 year (Required)

Work Location: In person

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