What are the responsibilities and job description for the Medical Records Director position at Sunset Nursing Rehabilitation Center Inc?
Job Description
Job Description
Medical Records Director
SHIFT : Full-Time, Monday - Friday 8am - 4 : 30 pm
Job Summary :
Maintains the integrity of the medical records from admission to discharge and final storage.
Job Responsibilities :
- Completes admission paperwork (facility specific)
- Computes admission / discharge face sheets upon admission and updates upon re-admission according to policy guidelines
- Requests specific medical information on a resident as needed from other facilities, MD, hospitals, etc.
- Reponsible for updating paperwork for any and all changes related to room changes, physician changes or contact information changes
- Assigns a code for all diagnosis : ICD-10 coding of the Admission / Discharge Record, Medicare determination forms
- Audits all active medical records on the nursing units for accuracy and completeness 14 days after admissions and re-admissions. 14-day chart audit policy is to be followed for long term residents
- Ensures that discharge summaries are completed according to policy on each planned discharge
- Closes all permanent discharge medical records according to policy and final chart analysis procedure
- Notifies Administrator / DON and all appropriate disciplines of any deficiencies found in either active or closed charts
- Retrieves and copies medical records as required promptly per policy and bills accordingly
- Notifies Administrator of all requests for information from medical records
- Protects all medical record information from loss, defacement or destruction after retention period ends
- Assures that all medical record information is protected and kept confidential
- Compiles the Dental / Podiatry / Optometry list and distribute to appropriate disciplines
- Maintains residents' rights
- Maintains HIPAA privacy, security, and confidentiality
- All other duties assigned by Administrator
Requirements :
Benefits :
Apply today and become a key part of our team in maintaining a comfortable, safe environment for residents and staff alike!
