Medical Records Director

Medical Records Director

Requirements

• Must possess, as a minimum, a high school diploma or GED.
• Must be able to type a minimum of 45 words per minute and use dictation equipment.
• Must be knowledgeable of medical terminology.
• Must be knowledgeable in computers, data retrieval, input and output functions, etc.
• Must be able to read, write, speak, and understand the English language.

Responsibilities

• Receive and follow work schedule/instructions from your supervisor and as outlined in our established policies and procedures.
• Assist in organizing, planning and directing the medical records department in accordance with established policies and procedures.
• Maintain minutes of meetings.
• File as necessary.
• Develop and maintain a good working rapport with inter department personnel, as well as other departments within the facility, to assure that medical records can be properly maintained.
• Assist in recording all incidents/accidents.
• File in accordance with established policies and procedures.
• Retrieve resident records (manually/electronically).
• Deliver as necessary.
• Files information such as nurses’ notes, resident assessments, progress notes, laboratory reports, x ray results, correspondence, etc., into resident charts.
• Collect, assemble, check and file resident charts as required.
• Assist MDS Coordinator in scheduling assessments in accordance with current facility and OBRA guidelines.
• Ensure incomplete records/charts are returned to appropriate departments or personnel for correction.
• Assist in developing procedures to ensure resident records are properly completed, assembled, coded, signed, indexed, etc., before filing.
• Establish a procedure to ensure resident charts/records do not leave the medical records room except as authorized in our policies and procedures.
• Maintain a record of authorized information released from charts/records, i.e., type information, name of recipient, date, department, etc.
• Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc. in accordance with current Privacy Rules.
• Index medical records as directed by the medical records/health information consultant.
• Maintain various registries as directed including register for admission and discharge of residents.
• Transcribe and type reports for physicians as necessary.
• Collect charts, assemble them in proper order, and inspect them for completion.
• Pick up and deliver resident medical records from wards, nurses’ stations, and other designated areas as necessary.
• Batch resident information into the computer and retrieve resident demographic information as appropriate or as instructed.
• Answer telephone inquiries concerning medical records functions.
• Prepare written correspondence as necessary.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies and personnel, etc.).
• Assure that medical records taken from the department are signed out and signed in upon return to the department.
• File active and inactive records in accordance with established policies.
• Index medical records as directed.
• Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.
• Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
• Report any known or suspected unauthorized attempt to access facility’s information system.
• Assume the administrative authority, responsibility, and accountability of performing the assigned duties of this position.
• Perform secretarial duties for committees of the facility as directed.
• Collect and assemble/compile records for committee review, as requested, and prepare reports for staff/other committees as directed.
• Report known or suspected incidents of fraud to the Administrator.
• Ensure that departmental computer workstations left unattended are properly logged off or the password protected automatic screen saver activates within established facility policy guidelines.
• Supervise staff, including taking appropriate disciplinary measures.
• Maintain census and report status changes.
• Attend and participate in mandatory facility in service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, etc.).
• Attend and participate in workshops, seminars, etc., as approved.
• Report all unsafe/hazardous conditions, defective equipment, etc., to your supervisor immediately.
• Report equipment malfunctions or breakdowns to your supervisor as soon as possible.
• Ensure supplies have been replenished in work areas as necessary.
• Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of workday, etc.
• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.

Preferred Qualifications

• A working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required.