JOB DESCRIPTION SUMMARY

Responsible for managing all aspects of maintaining and protecting organization clinical records including the management of the clinical records team.

POSITION QUALIFICATIONS

• Registered nurse with current licensure to practice professional nursing in the state.
• Previous experience in hospice/home care setting and with three (3) years management or supervisory experience. Proven ability to work within an interdisciplinary setting.
• Complies with accepted professional standards and practice.
• Has excellent observation, good nursing judgment and communication skills. Understands hospice philosophy and issues of death/dying.
• Understands principles of pain/symptom management.
• Must be a licensed driver with an automobile that is insured in accordance with state and/or organization requirements and is in good working order.
• Complies and maintains current CPR certification.
• Demonstrates excellent observation, verbal and written communication skills.
• Personal car for travel and valid driver’s license.
• Carry personal auto liability insurance coverage.
• At least three (3) years experience in clinical records management preferably in hospice care operations. Information systems knowledge required.
• Knowledge of corporate business management, governmental regulations andCHAP standards.
• Demonstrates good communication skills and public relations skills.
• Demonstrates autonomy, organization, assertiveness, flexibility and cooperation in performing job responsibilities.

• Reviews patient’s medical diagnosis, prognosis, medications, procedures and clinical course.
• Assists clinicians in establishing immediate and long-term therapeutic goals, in setting priorities, and in developing plan of care.
• Attends case conference meetings with hospice personnel to facilitate coordination of care and discussion of interdisciplinary group involvement.
• Conducts quarterly record reviews and communicates findings and recommendations to Clinical Director and hospice personnel
• Complies with accepted professional standards and principlesParticipates actively in quality assessment performance improvement teams and activities.
• Must be able to lift, position and/or transfer patients
• Must be able to drive during shift
• The person in this position frequently communicates with patients and their families. Must be able to exchange accurate information in these situations
• Must be able to be stationary and in a sitting position during shift.
• Must be able to complete tasks, including learning, remembering, focusing, categorizing, and integrating information for decision making, problem-solving, and comprehending.
• Performs other duties and activities as delegated by the Clinical Director.
• Assists Clinical Director and other supervisory hospice personnel in the planning, implementation and evaluation of in-service and continuing education programs. Assists in the formulating, revising, implementing, and evaluating organization policies, procedures, goals and objectives, both short and long range
• Ensures clinical record systems are maintained in compliance with state, federal and CHAP regulations.
• Maintains comprehensive working knowledge of state, federal, and CHAP documentation regulations and serves as a resource for appropriate organization personnel.
• Protects the confidentiality of patient and organization information through effective controls and direct supervision of clinical records.
  The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.