CONCORD HEALTH SYSTEMS

JOB DESCRIPTION

Nursing degree preferred

MEDICAL RECORDS DIRECTOR

• Ability to read/write, hear and communicate adequately to complete the job duties and responsibilities.
• Ability to move throughout the facility without assistance.
• Must be able to see adequately enough to read hand written medical records.
• Ability to effectively communicate with Administrators, Physicians, Health Care Professionals, and Concord Health Systems.
• Ability to establish procedures and the suggest changes for smoother operations.
• Basic data entry and computer skills. Understanding of the Medical Records systems, medical terminology, ICD coding, principles, concurrent and discharge analysis procedures, medical legal aspects, State and Federal Regulations, Concord Health Systems Policies and Procedures, and possess management skills for a long-term care facility.
• Personal attributes to include professionalism, neatness, detail oriented, accuracy, articulates pleasantly and cooperative with all staff.
• Perform specific duties on in-house medical records:
• Check the record quantitatively on admission, 14-day audits, and then periodically (not less than quarterly and monthly) to assure completeness, accuracy, and internal consistency between departments.
• Communicate with and assist the medical staff and allied health personnel in updating records.
• Place name labels on chart and next to room doors.
• Maintain the overflow file by removing outdated forms from the chart holder at the nursing station.
• Analysis and evaluation of medical records upon dismissal of the patient:
• Check discharge documentation quantitatively to assure completeness, accuracy, and internal consistency between departments.
• Obtain complete and accurate records within thirty (30) days.
• Assure all required reports are in the record.
• Follow appropriate procedures for closing a medical record permanently incomplete, if required.
• Arrange the medical record in the proper discharge order upon discharge of the patient.
• Department Head/Supervisory Duties:
• Attendance at all Department Head Meetings and Mandatory Staff In-Service Meetings. In addition, attends the Medicare Meeting, Safety Meetings, CQI Meetings, etc.
• Orientation of new staff to the Medical Record Department, and orientation to Nursing and other ancillary staff involved with documentation process. This will involve State and Federal Regulations as well as Concord Health Systems Policy and Procedure. Also, provide information on medical records functions and services.
• Plan the staffing needs of the Medical Record Department.
• Organize the flow of work within the department.
• Select equipment for the department.
• Interaction with all health care professionals, physicians, Administrators, and Concord Health Systems.
• Able to perform all functions and aspects of the Medical Record Department as necessary including assuming the duties of the Medical Record Unit Clerk if the facility does not have one on staff.

Job Type: Full-time

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Experience:

• Medical records: 1 year (Preferred)

Work Location: In person