Medical Records Director

Medical Records Director (Healthcare)

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 and file as necessary.

Develop and maintain a good working rapport with interdepartmental personnel, as well as other departments within the facility, to assure that medical records can be properly maintained. Assist in recording all incidents / accidents and file in accordance with established policies and procedures.

Retrieve resident records (manually / electronically) and deliver as necessary. File 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. 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. 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.

Committee Functions

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.

Personnel Functions

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.

Staff Development

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.

Safety and Sanitation

Report all unsafe / hazardous conditions, defective equipment, etc., to your supervisor immediately.

Equipment and Supply Functions

Report equipment malfunctions or breakdowns to your supervisor as soon as possible. Ensure supplies have been replenished in work areas as necessary.

Budget and Planning Functions

Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.

Other Duties as Assigned

This position has direct reports.

Qualification Education and / or Experience

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. A working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc., preferred but not required. On the job training provided in medical record and health information system procedures.

Language Skills

Must be able to read, write, speak, and understand the English language. Ability to read technical procedures.

Mathematical Skills

Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.

Reasoning Ability

Must possess the ability to make independent decisions when circumstances warrant such action. Must possess the ability to deal tactfully with personnel, residents, visitors and the general public.

Physical Demands

Must be able to move intermittently throughout the workday. Must be able to speak and write the English language in an understandable manner.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.

Additional Information

Note : Nothing in this job specification restricts management's right to assign or reassign duties and responsibilities to this job at any time.

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