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Date Posted: 12/29/2020
Location: York, PA 17404
Company: SpiriTrust Lutheran
Job Type: Full Time

SpiriTrust Lutheran is now hiring a FT Day Medical Records Specialist
For the third consecutive year, we have been certified as a Great Place to Work! 2020-2021
SpiriTrust Lutheran®delivers an array of programs and services that touch thousands of lives each day. Our name, SpiriTrust Lutheran®captures the essence of who we are and the care and compassion our amazing team delivers. It embraces our Lutheran heritage, our spirit of service, and the reality that people come to us because of their trust in us. 

At SpiriTrust Lutheran®, our employees are a highly valued resource. Their dedication, skill and commitment enable us to provide excellent service and care within our continuing care retirement communities, community outreach programs and home care services. We offer: Competitive salaries Comprehensive benefits package Education assistance Career advancement/professional growth Friendly, team-oriented environment If you are ready to join us for a rewarding career.  

Basic Qualifications
Education/Training:A high school diploma or equivalent.  Valid practical nurse license from the commonwealth of Pennsylvania, accredited records technician, or health records technician required.
Skill(s):Speak and understand English; proficient reading, writing, grammar, and mathematics skills; proficient interpersonal relations and communication skills; proficient keyboarding skills; proficient PC skills; knowledge of various office machines; general knowledge of assigned department’s operations. 
Experience:A minimum of one (1) year’s experience in medical records required; experience in long term care preferred.
General Responsibilities
Responsible for performing a variety of duties relative to the medical records function; ensuring safety and care of resident environment; providing residents with dignity and respect; achieving goals as established in the department’s annual operating plan; coordinating work within the department, as well as with other departments; reporting pertinent information to the immediate supervisor; responding to inquiries or requests for information.

Essential Duties

Supports the mission and values of SpiriTrust Lutheran which is: SpiriTrust Lutheran, witnessing to the Gospel of Jesus Christ, provides exceptional health, human, and senior living services by supporting persons in achieving an optimal quality of life.


Interacts with residents, clients, staff, and the general public in ways that demonstrate the agency’s commitment to courtesy, service, and hospitality befitting a church related organization.


Performs a variety of duties relative to the medical records function as follows:


Assembles, checks, codes, and files resident records as required (utilizing ICD9 classification system).


Assures that records are collected, assembled, and maintained appropriately, and are coded and inspected for completeness, and ensures that incomplete records are completed.


Abstracts information from records as authorized/required for insurance companies, Medicare, Medical Assistance, etc. and completes designated forms (MA 51, 103, Medicare Certifications and Recertifications).


Retrieves medical records when requested by authorized personnel, nurses, government agencies, etc.


Assists Medical Records consultant as required and follows up on recommendations made.


Recommends and develops procedures for assuring appropriate completion of medical records.


Performs miscellaneous duties pertaining to medical records including Quality Assurance tasks as designed by the Skilled Care Administrator.


Assumes the role of coach for new team members when requested, relating to medical records.


Completes required documentation for Medicare D; tracks physician visits for residents receiving Medicare B therapy, and completes required documentation for Medicare Detailed Notice.


Ensures safety and care of resident environment as follows:


Assures that work areas are kept clean, free of clutter, and are adequately stocked.


Performs all tasks in a safe manner, following established safety and infection control practices and procedures.


Attends in-service training to understand and participate in drills in order to demonstrate knowledge of assigned responsibilities with disaster, fire emergency, and elopement procedures; performs assigned responsibility in an emergency.


Reports all incidents/accidents to self, resident, or others immediately.


Provides residents with dignity and respect as follows:


Prevents, identifies, and reports actual or suspected abuse, neglect, exploitations, and improper use of chemical and physical restraints, in accordance with Agency standards.


Knows and respects all resident rights, while maintaining the confidentiality of all resident care information.


Accurately records time worked or not worked as illustrated by the following:


Accurately records time in and out at the start and end of each shift and at the start and end of each meal break utilizing the Agency’s timekeeping system.


Makes corrections to the timekeeping system as necessary, on appropriate forms within the required payroll timeframe.


Coordinates specific work tasks with other personnel within the department as well as with other departments in order to ensure the smooth and efficient flow of information.


Abides by the current laws and organizational standards and procedures designed and implemented to promote an environment which is free of sexual harassment and other forms of illegal discriminatory behavior in the work place.


Cooperates with, participates in, and supports the adherence to all Agency standards, procedures, and practices in support of risk management and overall safety and soundness and compliance with all regulatory requirements, i.e., HIPAA, OSHA, etc.; insures that the department and all personnel adhere to the same.


Abides by and supports the organization’s code of conduct by exhibiting behavior that is set forth in the code of conduct.  Performs duties in accordance with the code of conduct and completes annual compliance training.


Reports pertinent information to the immediate supervisor as requested, or according to an established schedule; compiles information as necessary or as directed and provides data to appropriate personnel.


Responds to inquiries or requests from customers, other personnel, etc., within given timeframes and within established policy.


Completes educational requirements as mandated by state and federal agencies to maintain competencies.