Medical Records Director directs medical record-keeping operations and healthcare information management to ensure secure, accurate, and reliable patient information management that complies with data and privacy regulations. Develops policies and procedures and conducts continuous improvement activities to ensure effective and compliant record management. Being a Medical Records Director implements digital technologies and tools to gain efficiencies, facilitate record retrieval, and ensure secure storage. Provides training for medical records staff and information resources to end-users. Additionally, Medical Records Director coordinates with clinical and technical professionals to maintain robust records management systems and manage data for analysis and reporting. Typically requires a bachelor's degree in healthcare administration, a related field, or equivalent. May require Registered Health Information Administrator (RHIA) certification. Typically reports to a director. The Medical Records Director typically manages through subordinate managers and professionals in larger groups of moderate complexity. Provides input to strategic decisions that affect the functional area of responsibility. May give input into developing the budget. To be a Medical Records Director typically requires 3+ years of managerial experience. Capable of resolving escalated issues arising from operations and requiring coordination with other departments. (Copyright 2024 Salary.com)
POSITION SUMMARY:
The Medical Records Director/Coder oversees all Health Information Management functions in accordance with guidelines and regulations. This is a self-directed position which requires the ability to meet deadlines and work quickly in a fast-paced and demanding work area.
DUTIES & RESPONSIBILITIES:
· Reviews medical records and assign diagnostic and procedure codes for inpatient, outpatient and discharged patient records
· Retrieves clinical information for the purposes of accurate MS-DRG assignment and ensures compliance with federal regulations
QUALIFICATIONS & REQUIREMENTS:
· Degree in Health Information Management, previous related training and experience required
· Current RHIT or RHIA registration and CCS/CPC-H is required.
· Must have a full understanding of HIPAA/ROI regulations and a working knowledge of Joint Commission Standards and UHDDS coding guidelines.
· Good communication skills and ability to work with others as a team member, with excellent office and clerical skills, organization and attention to detail required
· Courses/training to include medical terminology, anatomy & physiology, and coding and classification systems preferred
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