Medical Records Director

Required Qualifications

High school diploma or equivalent

Minimum of 2 years’ administrative experience preferred.

Working knowledge of medical terminology, anatomy and physiology, coding, and other aspects of health information strongly preferred.

Major Duties and Responsibilities

Organizes, plans and manages the medical records department in accordance with established policies and procedures.

Ensures resident health information is protected and not disclosed unless by permission or with established policies and procedures. 

Works closely with Nursing to ensure records are completed timely and include all required documents.

Assigned Tasks

Retrieves resident records (manually/electronically).  Delivers as necessary.

Files information such as nursing notes, assessments, progress notes, lab reports, x-ray results, correspondence, etc., either manually or electronically into resident charts.

Collects, assembles, checks, and files resident charts.

Ensures incomplete records/charts are returned to appropriate department or personnel for corrections.

Ensures resident records are properly completed, assembled, coded, etc., before filing.

Extracts information from records for insurance companies, Medicare, Medicaid, VA, etc., in accordance with established policies and procedures and privacy rules.

Picks up and delivers medical records to designated areas as necessary.

Answers telephone calls in regard to inquiries about medical records.  Prepares written correspondence as necessary.

Files active and inactive records as per established policies

Completes portion of death certificates as indicated.

Maintains logs of specific items as per established policies and procedures.

Maintains requests for medical records forms and completes as necessary.

Communicates with residents and visitors at the Nursing Station.

Helps to monitor call lite response times.

Attends daily Stand-up meetings to give status report.

May attend meetings with residents as needed, via in person or telephone. 

Other duties as assigned.

Personal Skills and Traits Desired/ Physical Requirements/Working Conditions

Ability to read, write, speak and understand the English language.

Must be a supportive team member, contribute to and be an example of team work.

Ability to make independent decisions when circumstances warrant such action.

Ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel and the general public.

Must have patience, tact, and willingness to deal with difficult residents, family and staff. 

Must be able to relay information concerning a resident’s condition.

Must not pose a threat to the health and safety of other individuals in the workplace.

Must be able to move intermittently throughout the workday.

Meets general health requirements according to facility policy, including medical and physical exams and checking immunity status to various infectious diseases.

Ability to work beyond normal working hours and on weekends and holidays when necessary.

Ability to assist in evacuation of residents during emergency situations.

Ability to bend, stoop, kneel, crouch, perform overhead lifting and perform other common physical movements as needed for the position.

May be subject to falls, burns from equipment, and/or odors throughout the day; encounter reactions from dust, tobacco smoke, disinfectants, and other air contaminants.

Subject to exposure to infectious waste, diseases and/or conditions which include AIDS, Coronavirus, Hepatitis B, and Tuberculosis.

May be subject to hostile or emotional residents, family members, visitors or personnel.

Must be able to follow oral and written instructions.

Must be able to move intermittently throughout the workday.

Mainly works in office but may work throughout the facility.

Compliance as a Condition of Employment and Performance Appraisal

Agreement to abide by all standards, policies, and procedures of the facility, including the facility’s compliance and ethics program, is a condition of employment.  Compliance will be a factor in evaluating job performance.  Violations, including failure to report violations, will result in disciplinary action, up to and including termination.

This job description is intended to convey the general scope of the major duties and responsibilities inherent in this position.  Other tasks not listed here may be assigned by the Administrator.  Periodic revision may be necessary to reflect changes in expectations placed on long term care by various governmental agencies.  This job description will be reviewed and/or revised annually and as needed.

Individual performance will be evaluated using the following scale: 

1. Unsatisfactory: Achieves results which are far less than the standards identified for the performance factors rated.
2. Needs Improvement: Achieves results which are less than the standards identified for the performance factors rated.  Exhibits the potential to become a competent performer.  May be new to job or need skill development.
3. Meets Standards: Achieves results which meet the standards identified for the performance factors rated.  This rating is the expected level of performance.
4. Exceeds Standards: Achieves results which usually exceed the standards identified for the performance factors rated.

Reasonable Accommodation Statement

Consistent with the Americans with Disabilities Act (ADA) and Oregon state civil rights law, it is the policy of The Holgate Center to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship.  The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process.  If reasonable accommodation is needed, please contact Sandra Speer HRDirector@holgatecenter.org.