Medical Records LPN

Join Our Team: Medical Records LPN

Cedar Sinai Park-Robison Jewish Health Center / Portland, OR

Job Summary

Cedar Sinai Park- Robison Jewish Health Center, is seeking a skilled and experienced LPN to work as Medical Records LPN here in Portland, OR. As an Medical Records LPN, you will be responsible for maintaining confidential, accurate medical records for our residents and responding timely to any requests for those records. If you are a motivated and detail-oriented professional with a passion for healthcare, we encourage you to apply.

Responsibilities:

Clinical Records Management

Maintain complete, accurate, current, and compliant clinical records for all residents.
Ensure all documentation is properly dated, signed, legible, and securely stored (or scanned).
Manage admission, transfer, discharge, and death records, including required logs and reports.
Maintain the master patient census and resident master index.

Auditing & Compliance

Conduct routine and scheduled audits of clinical records, physician orders, MAR/TAR, charting, and assessments.
Monitor compliance with admission, quarterly, annual, discharge, and physician documentation requirements.
Track and follow up on required physician visits, history and physical examinations, and signed orders.
Communicate audit findings, deficiencies, and follow-up needs with the Interdisciplinary Team (IDT).

Admissions, Discharges & Transitions

Review and verify clinical records for all admissions and readmissions within required timeframes.
Support admission, discharge, and transfer documentation and workflows.
Assist with new admission and readmission orders and coordinate communication with the Interdisciplinary Team.

Information Requests & Reporting

Process Release of Information requests in compliance with privacy regulations.
Extract and provide documentation for audits, insurance carriers, Medicare, Medicaid, VA, and regulatory agencies.
Complete required monthly and regulatory reporting, including death reports and Ombudsman discharge reporting.

Records Storage & Confidentiality

Maintain secure filing, storage, and retrieval systems for active and inactive records.
Track off-site stored records and ensure proper retention and accessibility.
Maintain confidentiality of resident records in accordance with HIPAA and Oregon Medical Records Association guidelines.

Interdisciplinary & Operational Support

Collaborate with nursing staff, providers, and leadership to ensure documentation accuracy and timeliness.
Participate in care conferences, resident engagement rounds, and Manager of the Day duties as assigned.
Order and maintain clinical record forms and related supplies.

Requirements:

High School diploma or equivalent with further education or equivalent in medical records forms and systems.
Licensed Practical Nurse (LPN), who is licensed in the State of Oregon and is in good standing with the Oregon State Board of Nursing.
Minimum of 2 years of experience in nursing, healthcare administration, medical records management, or a related field
Ability to work in a fast-paced environment with multiple priorities and deadlines
Strong leadership and communication skills
Knowledge of HIPAA and regulatory requirements
Well-versed in medical terminology, including ICD-10CM coding and indexing.
Experience with EMRs and electronic medical record systems RHIT preferred

Why Join Us:

At Cedar Sinai Park, we are dedicated to providing compassionate and person-first care to our residents. Our organization is built on a foundation of Jewish values, and we prioritize cultural background, faith, and autonomy in our care. As part of our team, you will have the opportunity to make a meaningful impact in the lives of our residents and contribute to an organization that is truly making a difference.

How to Apply:

If you are a motivated and experienced professional looking for a new challenge, please apply for this exciting opportunity to join our team.

Share this job

Related Jobs

Ambulatory LPN - Occupational Medicine - FT - Day

Stormont-Vail HealthCare Battle Ground, WA

Position Status: Full time Shift: First Shift (Days - Less than 12 hours per shift) (United States of America) Hours per week: 40 Job Information Exemption Status: Non-Exempt A Brief Overview Work Care is a specialty within the nursing profession that encompasses the care of workers from a variety of settings. The Work Care LPN responsibilities include, but are not limited to, patient assessment and triage, excellent communication and customer service skills, educating and answering patient questions during visit and at discharge. The Work Care LPN rooms patients, takes vital signs, collects specimens and reports patient concerns or pertinent observations to provider. The Work Care LPN is responsible for coordination of tests and services, assisting providers with procedures, and accurate documentation of all patient related activities. The Work Care LPN may also perform procedures and testing under indirect physician supervision. Responsible to provide a safe environment for his/her assigned patients; to complete the assigned work; and to document and report any pertinent observations as a result of the interventions. The delivery of professional nursing care at Stormont Vail Health is guided by Jean Watson's Theory of Human Caring and the theory of Shared governance, both of which are congruent with the mission, vision, and values of the organization. Experience Qualifications Experience in a clinic setting. Preferred Experience providing patient care. Preferred Skills and Abilities Demonstrates consistent use of Standard Precautions and proper body mechanics and follows OSHA guidelines (Required proficiency) Demonstrates knowledge of the Kansas State Nurse Practice Act and follows the statutes and regulations therein. (Required proficiency) Responsible for understanding and showing respect for patients’ rights including confidentiality of patient information. (Required proficiency) Demonstrates excellent understanding and use of the EMR (Required proficiency) Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization. (Required proficiency) Licenses and Certifications Licensed Practical Nurse - KSBN A multistate license with the ability to practice within the State of Kansas is also accepted. Required Basic Life Support - BLS Required within 90 days of hire. What you will do Implements identified plan through coordination of care with interdisciplinary care team to employ strategies to promote health and wellness. Performs tests and specimen collections (ie- drug testing, blood collection, breath alcohol testing, respiratory fit-testing, pulmonary function testing, audio & vision testing) as ordered and according to proper procedures. Collaborates with interdisciplinary care team encompassing strategies to achieve expected outcomes. Promote infection prevention through use of standard precautions, proper procedure in dressing changes, wound care, hand hygiene and cleanliness of the patient rooms/department. Communicates pertinent data and information relative to the patient, situation, or setting in a timely manner Delivers professional nursing care guided by Jean Watson’s Theory of Human Caring illustrated by creating caring relationships, taking time to have uninterrupted moments with patients and displaying unconditional acceptance and respect. Promotes a mutually respectful environment that encourages the exchange of ideas and supports the effectiveness of professional relationships and integrates ethics in all aspects of practice. Demonstrates advocacy in all roles and settings. Practices Diversity, Equity and Inclusion principles in their daily work by respecting others’ uniqueness, perspectives, backgrounds or beliefs. Communicates effectively in all areas of professional practice. Mentors nurses new to their role for the purpose of ensuring successful enculturation, orientation, competence, and emotional support. Supports students to enhance their knowledge, skills, and abilities. Commits to lifelong learning through critical thinking, self-reflection, and inquiry for personal growth and development. Demonstrates willingness to participate and lead nursing practice in process evolution the scope of the Stormont Vail Health professional practice model. Utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and financially responsible, and used judiciously. Required for All Jobs Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health Performs other duties as assigned Patient Facing Options Position is Patient Facing Remote Work Guidelines Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards. Stable access to electricity and a minimum of 25mb upload and internet speed. Dedicate full attention to the job duties and communication with others during working hours. Adhere to break and attendance schedules agreed upon with supervisor. Abide by Stormont Vail’s Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually. Remote Work Capability On-Site; No Remote Scope No Supervisory Responsibility No Budget Responsibility Physical Demands Balancing: Occasionally 1-3 Hours Carrying: Occasionally 1-3 Hours Climbing (Ladders): Rarely less than 1 hour Climbing (Stairs): Rarely less than 1 hour Crawling: Rarely less than 1 hour Crouching: Occasionally 1-3 Hours Driving (Automatic): Rarely less than 1 hour Driving (Standard): Rarely less than 1 hour Eye/Hand/Foot Coordination: Frequently 3-5 Hours Feeling: Occasionally 1-3 Hours Grasping (Fine Motor): Occasionally 1-3 Hours Grasping (Gross Hand): Frequently 3-5 Hours Handling: Frequently 3-5 Hours Hearing: Occasionally 1-3 Hours Kneeling: Occasionally 1-3 Hours Lifting: Occasionally 1-3 Hours up to 50 lbs Operate Foot Controls: Rarely less than 1 hour Pulling: Occasionally 1-3 Hours up to 25 lbs Pushing: Occasionally 1-3 Hours up to 25 lbs Reaching (Forward): Occasionally 1-3 Hours up to 25 lbs Reaching (Overhead): Occasionally 1-3 Hours up to 25 lbs Repetitive Motions: Occasionally 1-3 Hours Sitting: Occasionally 1-3 Hours Standing: Occasionally 1-3 Hours Stooping: Occasionally 1-3 Hours Talking: Occasionally 1-3 Hours Walking: Occasionally 1-3 Hours Working Conditions Burn: Rarely less than 1 hour Chemical: Rarely less than 1 hour Combative Patients: Occasionally 1-3 Hours Dusts: Rarely less than 1 hour Electrical: Rarely less than 1 hour Explosive: Rarely less than 1 hour Extreme Temperatures: Rarely less than 1 hour Infectious Diseases: Occasionally 1-3 Hours Mechanical: Rarely less than 1 hour Needle Stick: Occasionally 1-3 Hours Noise/Sounds: Occasionally 1-3 Hours Other Atmospheric Conditions: Rarely less than 1 hour Poor Ventilation, Fumes and/or Gases: Rarely less than 1 hour Radiant Energy: Rarely less than 1 hour Risk of Exposure to Blood and Body Fluids: Occasionally 1-3 Hours Risk of Exposure to Hazardous Drugs: Occasionally 1-3 Hours Hazards (other): Rarely less than 1 hour Vibration: Rarely less than 1 hour Wet and/or Humid: Rarely less than 1 hour Stormont Vail is an equal opportunity employer and adheres to the philosophy and practice of providing equal opportunities for all employees and prospective employees, without regard to the following classifications: race, color, ethnicity, sex, sexual orientation, gender identity and expression, religion, national origin, citizenship, age, marital status, uniformed service, disability or genetic information. This applies to all aspects of employment practices including hiring, firing, pay, benefits, promotions, lateral movements, job training, and any other terms or conditions of employment. Retaliation is prohibited against any person who files a claim of discrimination, participates in a discrimination investigation, or otherwise opposes an unlawful employment act based upon the above classifications.

LPN

Part-time

1 week ago

RN/LPN

Monte Nido & Affiliates, LLC West Linn, OR

We save lives while providing the opportunity for people to realize their healthy selves. Registered Nurse/ Licensed Practical Nurse Monte Nido Clementine Lake Oswego West Linn, Oregon Monte Nido Clementine Lake Oswego, located in West Linn, OR is a residential treatment program exclusively for adolescents seeking treatment for Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, or Exercise Addiction. At Clementine , we support adolescents and their families on the path to full recovery by preparing each adolescent to navigate the challenges of life free of the eating disorder. We provide the empathy, education, and support to families as partners in the recovery process. We help each adolescent to replace the eating disorder with healthy skills and a deep understanding of how to live a life that reflects their own unique individuality. We are seeking a part-time Registered Nurse (RN) or Licensed Practical Nurse (LPN) to join the Clementine team. Availability reqiured: Overnights (7p-7a) - Wednesday #LI-ONSITE Total Rewards: We are committed to creating a diverse environment and are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. Responsibilities Include: Obtaining and recording vitals as needed. Monitoring and reporting unusual client behavior. Medication administration. Document promptly and properly. Model normalized dietary habits by eating meals to completion when working during mealtimes. Qualifications: Active license as Registered Nurse (or be license-eligible). Experience in residential or inpatient behavioral health and mental health settings is helpful. Any past work with those overcoming Eating Disorders is a plus. Must hold active CPR/BLS prior to starting work. (We can arrange training if needed). #clementine

LPN

Per Diem

2 weeks ago

RN/LPN

Monte Nido & Affiliates, LLC West Linn, OR

We save lives while providing the opportunity for people to realize their healthy selves. Registered Nurse/ Licensed Practical Nurse Monte Nido Clementine West Linn West Linn, Oregon Monte Nido Clementine West Linn, located in West Linn, OR is a residential treatment program exclusively for adolescents seeking treatment for Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, or Exercise Addiction. At Clementine , we support adolescents and their families on the path to full recovery by preparing each adolescent to navigate the challenges of life free of the eating disorder. We provide the empathy, education, and support to families as partners in the recovery process. We help each adolescent to replace the eating disorder with healthy skills and a deep understanding of how to live a life that reflects their own unique individuality. We are seeking a per diem Registered Nurse (RN) or Licensed Practical Nurse (LPN) to join the Clementine team. Availability reqiured: Overnights (7p-7a) Saturday or Sunday. #LI-ONSITE Total Rewards: We are committed to creating a diverse environment and are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. Responsibilities Include: Obtaining and recording vitals as needed. Monitoring and reporting unusual client behavior. Medication administration. Document promptly and properly. Model normalized dietary habits by eating meals to completion when working during mealtimes. Qualifications: Active license as Registered Nurse (or be license-eligible). Experience in residential or inpatient behavioral health and mental health settings is helpful. Any past work with those overcoming Eating Disorders is a plus. Must hold active CPR/BLS prior to starting work. (We can arrange training if needed). #clementine

LPN

Per Diem

1 month ago

RN/ LPN

Monte Nido & Affiliates, LLC West Linn, OR

We save lives while providing the opportunity for people to realize their healthy selves. Registered Nurse/ Licensed Practical Nurse Monte Nido Clementine Lake Oswego West Linn, Oregon Monte Nido Clementine Lake Oswego, located in West Linn, OR is a residential treatment program exclusively for adolescents seeking treatment for Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, or Exercise Addiction. At Clementine , we support adolescents and their families on the path to full recovery by preparing each adolescent to navigate the challenges of life free of the eating disorder. We provide the empathy, education, and support to families as partners in the recovery process. We help each adolescent to replace the eating disorder with healthy skills and a deep understanding of how to live a life that reflects their own unique individuality. We are seeking a per diem Registered Nurse (RN) or Licensed Practical Nurse (LPN) to join the Clementine team. Schedule : Day shift (7a-7p) a nd Overnights (7p-7a) rotating weekend availability required; our prn schedules require 2 shifts a month #LI-ONSITE Total Rewards: We are committed to creating a diverse environment and are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. Responsibilities Include: Obtaining and recording vitals as needed. Monitoring and reporting unusual client behavior. Medication administration. Document promptly and properly. Model normalized dietary habits by eating meals to completion when working during mealtimes. Qualifications: Active license as Registered Nurse (or be license-eligible). Experience in residential or inpatient behavioral health and mental health settings is helpful. Any past work with those overcoming Eating Disorders is a plus. Must hold active CPR/BLS prior to starting work. (We can arrange training if needed). #clementine

LPN

Per Diem

1 month ago

RN/LPN

Monte Nido & Affiliates, LLC West Linn, OR

We save lives while providing the opportunity for people to realize their healthy selves. Registered Nurse/Licensed Practical Nurse Monte Nido Portland West Linn, OR Monte Nido Portland, located in West Linn, OR is a residential treatment program exclusively for adults seeking treatment for Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, or Exercise Addiction. Monte Nido’s treatment approach focuses on the restoration of physiological and nutritional balance, implementation of healthy eating and exercise routines, elimination of harmful behaviors, and development of motivation and treatment engagement. Our objective is to help each client achieve a clear understanding of their eating and/or exercise disorder and its effect on their life, as well as an individualized appreciation of what is necessary for their personal recovery. The primary responsibility of the Nurse is evaluation, monitoring, planning, administration, and direct delivery of patient-care services. Maintains a current nursing license in the State of practice. This position is responsible for nursing assessment plans and overseeing the medical and psychiatric management of the patient in coordination with the attending providers. The Nurse is also a member of the Treatment Team and provides input into the development of the Master Treatment Plan. The Nurse functions under the guidance of their State Licensure within the facility in accordance with State and Federal regulations. We are seeking a per diem Nurse to join the Monte Nido team. Availability need for Saturdays 7a-7p #LI-ONSITE Total Rewards: We are committed to creating a diverse environment and are proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. Responsibilities Include: Essential Duties and Responsibilities Initiates the admission process by obtaining provider orders upon patient arrival at a residential facility and completing the initial nursing assessment within 24 hours, including assistance with medical intake (patient history and physical). Performs vital sign monitoring, including orthostatic vitals and blind weights as ordered by the provider; conducts patient assessments and documents findings in detailed nursing notes. Monitors and documents patient progress or regression in accordance with established policies and procedures. Assists providers in facilitating weekly patient consultations. Offers education and support to help patients develop the skills needed for safe self-administration of medications after discharge. Ensures accurate placement of medications in the designated medication box and updates the medication administration record (MAR) accordingly. Supports patients in obtaining medications from the pharmacy, including facilitating initial medication orders. Coordinates and facilitates the collection of laboratory specimens as ordered, ensures timely receipt of results, and communicates findings to the medical team for appropriate follow-up. Other Duties and Responsibilities Demonstrates knowledge of medication actions, side effects, and contraindications, and is responsible for researching unfamiliar medications prior to administration to ensure safe and informed care. Collects and records data in a comprehensive, accurate, and systematic manner. Responsible for maintaining patients’ records updated in electronic system. Supports a therapeutic milieu by monitoring patient behaviors, fostering a recovery-focused environment, and collaborating with the treatment team to reinforce structure, safety, and consistency. Communicates relevant information obtained from patients or families to the interdisciplinary team to support individualized care planning and treatment continuity. Coordinates with the Primary Therapist on any insurance review information needed. Works collaboratively with medical and psychiatric teams to provide integrated nursing care in support of eating disorder treatment goals. Participates in discharge planning with the medical and psychiatric teams to ensure continuity of care and safe transition from eating disorder treatment. Attend monthly nurse-led meetings and other team meetings as they arise to support effective communication and collaboration. Provides health education to patients through individual or group sessions when appropriate and documents sessions clearly, accurately, and concisely using the designated form. Assist patients in the coordination of their outpatient appointments as needed. Supports the informed consent process by helping patients understand procedures and treatments under the direction of the provider. Knows Baker Act (Florida Only) Delivers clinical nursing care in a safe, competent, and professional manner in accordance with established standards and protocols. Adheres to established standards of nursing practice and organizational policies. Completes required onboarding and annual training within designated timeframes and attends monthly clinical services training or other training as scheduled, in accordance with organizational policies and procedures. Demonstrates professionalism and serves as a positive role model for patients and staff within the therapeutic environment. Promptly reports suspected patient rights violations by established protocols. In an emergency or declared state of emergency, it may be required to stay on-site as a part of the emergency team until the emergency has ended. Performs other tasks, as assigned. Qualifications: Graduate from an accredited school of nursing is required. A minimum of one year of experience, preferred. Valid Nursing licensure required. Virtual Programs - Multistate Nursing license, preferred. CPR/First Aid certification required. Good communication skills, guest relations skills Service-oriented, takes initiative Good attendance and punctuality; dependability Strong safety awareness Organized use of time Cooperation, working as a team member, and flexibility. #montenido