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)
Responsible for maintaining resident medical records in accordance with State and Federal regulations, professional standard of practice and company policy and procedure. Responsible for ensuring the management and accuracy of medical resident records from pre-admission to post discharge.
GENERAL DUTIES
• Manages resident health information by ensuring resident records remain accurate, complete, current, confidential, and are compliant with federal and state regulations, HIPAA, and company policies and procedures.
• Ensures accurate and current diagnostic coding to assure appropriate billing, to maximize accounts receiving and improve cash flow.
• Establishes and executes procedures in the collection, coding and indexing, and the filing/retrieving of medical records; Performs ICD coding; creates medical records for all new admissions.
• Must be knowledgeable on federal and state laws regarding medical records; Ensures resident records are maintained accurately and timely according to local, state and federal regulations; Performs monthly audits on: admissions, discharge and routine Quality Assurance
• Ensures that registries are properly maintained for admission and discharge of residents.
• Protects medical records from breaches of confidentiality.
QUALIFICATIONS
• Minimum of 2 years’ experience in medical records in skilled nursing facility or healthcare related field, preferably an LPN or licensed CMA
• Experience with ICD coding preferred and general knowledge of medical supplies
• Knowledgeable of medical terminology, laws, and regulations, as they pertain to long term care.
• Possess effective communication skills to maintain positive relationship with residents, families, staff, physicians, consultants, providers, and governmental agencies, their representatives and the community.
• RHIA or RHIT credential preferred.
BENEFITS
· 401K
· Annual evaluations
· Dental insurance
· Disability insurance
· Electronic documentation
· Employee appreciation events
· Health insurance
· Life insurance
· Paid time off
· Tuition reimbursement
· Vision insurance
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