What are the responsibilities and job description for the Medical Records Director position at Vestracare?
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 before 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:
- High School diploma or GED
- Valid NYS Driver's License
- Medical Records Experience
- Excellent organizational, communication, and decision-making skills
Benefits:
- Paid Time Off (PTO)
- Health, Vision, and Dental Insurance
- Life Insurance
- Referral Bonus Program
- Weekly or Same Day Pay Options
- Supportive Work Environment
Apply today and become a key part of our team in maintaining a comfortable, safe environment for residents and staff alike!
