Clinical Records Administrator

4 days ago


Leamington Spa, Warwickshire, United Kingdom Care New England Health System Full time

Career Opportunities at Care New England Health System

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We are a leading healthcare organization dedicated to delivering high-quality patient care and services. Our mission is to improve the health and well-being of our community through excellence in clinical care, research, and education.

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In this role, you will be working closely with our team of healthcare professionals to maintain accurate and up-to-date medical records. Your attention to detail and organizational skills will be crucial in ensuring the smooth operation of our medical records department.

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Responsibilities:

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  • Manage all documentation of patient records, including admissions, services provided, and discharges.\
  • Print 485's, physician orders, and other clinical documentation for both Medical Surgical and Hospice units.\
  • Send documentation/orders to physicians via fax, mailings, and/or uploads into Doc Center.\
  • Track to ensure signed physician orders are received by the agency according to standard (14-30 days), run Outstanding report tracking, and run Incomplete report (5-day window of start of care date for Certification/recertification report, CTI's, Hospice Certifications/recertification's, Hospice Face to Face).\
  • Follow up with the physician office for orders not received within agency guidelines and document call in episode note.\
  • Notify coordinator after two attempts to obtain orders if unsuccessful.\
  • Run Outstanding Report for both Med Surgical and Hospice documents.\
  • Identify any changes/discrepancies in physician demographics, i.e., address, phone number, and notify manager of finance to update physician demographics.\
  • Identify discrepancies on all orders of start of care date, diagnosis codes, verification of data corruption of clinician's authorship.\
  • Making corrections to the system and document changes in episode note.\
  • Obtain documentation from medical records as needed.\
  • Problem solve incorrect or incomplete information to ensure receipt of signed orders.\
  • Run and review system reports to manage document tracking.\
  • Document any privacy issues according to agency guidelines.\
  • Identify trends related to incomplete/inaccurate documents and report same to coordinator.\
  • Review designated vendor reports (McBee) to process certifications and recertifications.\
  • Notify clinician to lock documents.\
  • Receive faxes and mail from physicians' offices and any clinical paperwork that pertains to medical records.\
  • Sort received information.\
  • Obtain correct medical record.\
  • Review MOLST forms for completeness and send to provider for signature.\
  • Send IDG Notes to designated provider by fax, mail, or portal.\
  • Submit designated record requests to vendor (Sharecare) for processing and document the required elements in the EMR.\
  • Retrieve required documents for regulatory and other agencies as needed.\
  • Check that consents are on file for all patients and notify admit clinician and manager if consent is missing.\
  • Cross train to answer reception calls from front desk and overhead telephone bell assistance.\
  • Assist in development of agency medical records education.\
  • Assist in the development of agency processes and procedures.
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Education:

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A high school diploma or equivalent is required. One year of related experience is preferred.

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Salary:

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$45,000 - $65,000 per annum, depending on experience.

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Work Environment:

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You will be working in a fast-paced medical records department, interacting with healthcare professionals and patients. A clean and organized work environment is expected.

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We offer a comprehensive benefits package, including medical, dental, and vision insurance, 401(k) retirement plan, and paid time off.



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