The Medical Records Specialist is responsible for assessing, monitoring, and reporting on all components of the documentation of the person supported’ s medical services. The Medical Records Specialist will coordinate with team members to ensure medical aspects of person supported are completed including but not limited to appointments, electronic health record documentation, and follow-up medical needs. The role will track, monitor, and ensure that all the person supported’ s medical records are updated within regulatory time frames. This position is responsible for reviewing and coordinating the scheduling of all annual, follow-up, and emergency medical appointments. This includes communicating with all levels of leadership, medical staff, Direct Support Professionals and external stakeholders.

Essential Functions:

• Under the direction of the Residential Operations Manager, the primary responsibility is to ensure scheduling all client medical appointments in compliance with state mandated licensing regulations and that all required documentation is accurate, complete, and uploaded to the EHR system.
• Observes and tracks all aspects of clients' medical care including, but not limited to annual and emergency appointments.
• Will advise LPN and Residential Program Supervisors of any upcoming appointments as well as medication or documentation issues.
• Ensures that the EHR is up to date with any changes in medical status including but not limited to: diagnosis, medication, appointments, and documentation.
• Cooperates with audits, inspections, and investigations.
• Audits all information prior to annual licensing to ensure it meets regulatory requirements.
• Participates in team meetings, when needed, with LPN, Residential Program Supervisors, Behavior Specialist, and Direct Support Professionals.
• Tracks information related to current psychotropic PRN medications and documentation when administered.
• Updates HRST with information including but not limited to: medication and diagnosis changes.
• Acts in accordance with all agency policies, state and federal regulations, local monitoring standards, and contractual requirements.

• Reports all violations of agency policies, state or federal regulations, local monitoring standards, or contractual requirements immediately to Residential Operations Manager.

• Monitors the medical records within the Electronic Health Record (EHR), and routes to the program supervisor information related to person supported that need addressed.

• Ensures timely completion and submission of medical documentation by team members in conjunction with all applicable regulatory guidelines.

• Audit eMAR system regularly and provide reports to Residential Program Supervisors regarding missing information or low medication counts.

• Additional tasks and responsibilities may be assigned.

Other duties:

• Complies with all InVision Human Services policies, procedures, and standard business practices
• Correctly and accurately completes and submits by stated deadline, InVision Human Services required documents such as timesheets and expense reports
• Submits required information such as physical examinations, vehicle insurance and vehicle registration administrative staff as requested by stated deadlines
• Adheres to schedule for arrival time, scheduled appointments, and other company related meetings
• Attends training as required and attends regularly scheduled supervision with Residential Operations Manager.
• Ensures completion of regulatory required annual training hours.

• Proactively feeds information upwards to keep management well informed of issues effecting operations

• Utilizes computer equipment and programs to provide for efficient and effective communication and workflow
• Takes personal responsibility for own learning and development that contribute to professional growth
• Creates and maintains effective interpersonal working relationships and functions as a member of the residential program team

Behavior Requirements:

The following constitute the behavior expectations the company has for each employee:

• Treats everybody with dignity and respect
• Is honest and trustworthy
• Respects authority and the chain of communication
• Exhibits a willingness and desire to learn about the company and its philosophies
• Exhibits empathy
• Respects other’s opinions, beliefs, and position on a matter, even if it contradicts his/her own
• Understands the importance of, and practices respectful disagreement
• Follows fundamental business etiquette and protocols
• Complies with all policies and regulations
• Projects a positive attitude and image of the company internally and externally

Education and Experience:

• High School Diploma or GED required; Bachelor’s Degree preferred
• Valid driver’s license, vehicle registration and current vehicle insurance
• Complete all state and agency required training per state guidelines
• Ability to establish a comfortable and supportive relationship with individuals receiving supports
• Ability to exercise good judgment and remain calm in crisis situations

• Excellent verbal and written communication skills

• Advance typing and computer skills required to perform the responsibilities.

Other Requirements:

• Able to react to change productively and handle other essential tasks as assigned.
• Develop and maintain effective communication and working relationships with staff, co-workers, and person supported
• Maintain professional, confidential, and ethical standards guidelines by InVision and other entities.

PHYSICAL DEMANDS:

While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand and walk. The employee is occasionally required to sit; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl; and taste or smell. The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.

All job requirements listed indicate the minimum level of knowledge, skills, and/or ability deemed necessary to perform the job proficiently. This job description is not to be construed as an exhaustive statement of duties, responsibilities, or requirements. Employees may be required to perform any job-related function as directed by their supervisor.