Cavalier Healthcare of Trussville LLC·Trussville, Alabama
Manage resident medical records to ensure they are complete, accurate, and compliant with state and federal regulations. Perform regular audits of admission and discharge charts and maintain diagnosis lists and form inventories.
Description To manage the medical records on each resident in accordance with established facility protocol, standards of practice and state and federal regulations and to ensure that these records are complete, accurately documented, readily accessible and systematically organized.
Accountability: Director of Nursing
Assemble admission records. Preform regular audits to verify completeness, accuracy and internal consistency of each record. Audit discharge charts for accuracy and completeness; file in the appropriate order. Perform coding and maintain a diagnosis list on each medical record. Participate in Case Mix audits providing assistance as needed. Maintain an inventory of all forms used in medical records. Answer the telephone courteously and relay messages. Perform or assist with monthly reviews of incident/accident reports for nursing. Provide administrative support, as requested. Understand and follow fire, safety, sanitation, Blood-borne Pathogen rules and Hazard Communication programs. Promote a positive relationship with residents, visitors, and government regulators to include a professional attitude and appearance. Prevent abuse, neglect and exploitation in the elderly. Promote a safe, clean environment in which the residents may live. Any other duties and responsibilities, as requested by the Administrator. Become a participating facility team member with the residents as first priority. Attend facility meetings.
PHYSICAL REQUIREMENTS: Hold/handle Lift Carry Reach – at and below shoulder height Push/pull Grasp and handle – pens, paperwork and small equipment Sit, stand and walk Twist, bend, stoop, kneel, and squat Fine hand motor coordination Ability to read and write legibly Ability to comprehend and follow instructions COGNITIVE AND SENSORY REQUIREMENTS: Talking: Communicating with residents, families, visitors and staff Hearing: To communicate effectively on the telephone, Taking instructions from the Administrator, To respond appropriately to disaster instructions and pages Sight: For performing job effectively and correctly Smell: For accurate detection and maintenance of facility odors LICENSURE REQUIREMENTS: Must be a Licensed Practical Nurse (L.P.N.) currently licensed and in good standing with the Board of Nursing in the State in which the facility is located. SUMMARY OF OCCUPATIONAL EXPOSURE: Tasks and procedures performed by the employee involve risks classified by C.D.C. as Category III. (No contact with blood or other bodily fluids to which universal precautions apply, if regular duties are performed.) OTHER CONSIDERATIONS AND REQUIREMENTS: Must be able to tolerate a high pace as typical for a nursing facility. Must be able to take and give instructions well and enjoy working with the elderly. Although employee is required to sit for prolonged periods of time, he/she must also be able to tolerate prolonged standing and walking.
Market context
Nursing roles in Alabama typically stay active across hospitals, clinics, and other care settings, especially when units need licensed RNs who can start quickly. These positions can be competitive because employers often look for current Alabama or multistate RN licensure, BLS, and education that meets the unit’s needs, with BSN or specialty certifications sometimes preferred. Review the unit-specific certification timeline and compare the AI-summarized requirements and benefits here with the original posting to save research time before applying.
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