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 DESCRIPTION:
Assists in developing and maintaining an appropriate health record service and system for the center.
QUALIFICATIONS
• High School diploma.
• Strong written and verbal skills in English necessary for business.
• Administrative and organizational ability.
• Knowledge of medical terminology.
• Previous experience in a skilled nursing home health care setting.
• Prior health record experience preferred.
• Basic computer experience preferred.
GENERAL DUTIES AND RESPONSIBILITIES:
ADMINISTRATIVE
• Maintains Health Record System according to Federal, State and Community requirements.
• Participates in assigned meetings and inservices.
TECHNICAL
• Initiates Resident Health Record.
• Initiates and maintains logs and indices as required:
• Admission/Discharge Register
• Master Patient Index
• Disease Index
• Medicare Log (if applicable)
• Audit System
• Discharge Control Log
• Chart Removal Log
• Resident Care Plan Log
• Telephone Audit Log
• Performs Audits
• Admissions
• Discharge
• Routine Quality Assurance Audits
• Special as required
• Coordinates Physician Documentation
• Telephone Orders
• History and Physicals
• Monthly Physicians Orders
• Physicians’ Progress Notes
• Certifications and Recertifications
• Discharge Summaries
• Thins charts and maintains overflow files as required.
• Records and maintains minutes of meetings as assigned.
• Inputs and prints computerized medical records forms.
• Prepares statistical reports as required.
• Destroys old health records as required.
• Assembles, analyzes and completes discharge records.
• Maintains unit filing system.
CONSUMER SERVICE
• Presents professional image to consumers through dress, behavior and speech.
• Adheres to Company standards for resolving consumer concerns.
• Ensures that all consumer/resident rights are protected.
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