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)
General Purpose:
This position maintains the medical records for the facility in accordance with policies and procedures established for the medical record keeping, under the guidance of the Health Information Consultant.
Qualifications:
Medical Record Technician
Medical Record Practitioner
Duties and Responsibilities
1) Assure that the resident is properly registered in the necessary indices of the facility (i.e. Resident Number Register and Master Patient Index).
2) Code admission diagnoses according to the ICD-10 CM coding guidelines and principles and enter codes into appropriate system(s), as required.
3) Assure the admission summary (face sheet) is complete.
4) Upon discharge, check records quantitatively to assure completeness and accuracy within thirty (30) days of the discharge or in accordance with state regulations.
5) Determine whether additional transfer data is needed and request from transferring facility if needed. Follow-up to assure receipt.
6) Check the record quantitatively on admission and periodically to assure
completeness, accuracy and internal consistency. Report trends to the QA/QAPI committee.
7) Communicate with and assist the medical staff and allied health personnel in updating records.
8) Maintain the flow of the reports to the records.
9) Update diagnostic lists as changes occur by coding additional diagnoses documented by physician and resolving inactive diagnoses. Review diagnostic lists for accuracy in
conjunction with the MDS schedule and sign for accuracy of MDS Section I, as required.
10) Check the discharge documentation quantitatively to assure completeness, accuracy, and internal consistency.
11) Obtain complete and accurate records within thirty (30) days of discharge or in accordance with state regulations.
12) Assure face sheet discharge information is correct.
13) Assure all required reports are in the record.
14) Follow appropriate procedures for closing a record permanently incomplete, if required.
15) Maintain the Resident Number Registry.
16) Verify the accuracy of the Master Resident Index upon admission and discharge of the resident.
17) Maintain overflow records.
18) Maintain a tracking system for physician visits and the authentication of orders.
19) Maintain accurate and timely Medicare certifications, as required.
20) Collect, correlate and maintain statistical data as needed.
21) Provide information, when requested, to those involved in research projects and studies with the approval of center administrator.
22) Assist the medical staff by providing data from the health records for Utilization Review, Triple Check, QAPI and various audits.
23) Maintain the numerical filing system for records.
24) Maintain the unit numbering system for record identification.
25) Maintain the necessary sign-out and follow-up controls of records.
26) Maintain and control release of information to authorized persons.
27) Type and/or transcribe reports of correspondence according to the needs of the HIM department.
28) Attend facility meetings as required.
29) Orientation of new staff members to the HIM department. Orientation and training
of nursing and ancillary departments involved in documentation process. This will involve both state and Federal regulations and center policies and procedures, as well as documentation recovery education.
30) Ensure medical record copies are provided per policy and/or regulation to the appropriate resident and/or resident representative.
31) Ensure medical record copy fees are charged and collected per policy.
32) Ensure legal medical record requests are copied, prepared neatly, reviewed prior to delivery and sent/delivered in the specified time frame.
33) Responsible for the evaluations, scheduling and disciplinary action of health information employees within the department.
34) Determination of budgetary needs for both routine and capital expenditures, in conjunction with the administrator.
35) All other duties as assigned.
Physical and Sensory Requirements: Walking, sitting, standing, reaching, stooping, bending, lifting, grasping, pushing and pulling, and fine-hand coordination. Ability to hear and respond to overhead pages. Ability to communicate with residents, families, personnel, vendors, and consultants. Ability to apply training and in-service education provided. Must present a neat, clean, professional appearance and demonstrate a positive approach with employees and residents.
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