Medical Records Director

1 week ago


Lancaster, United States PACS Inc Full time

Maintain and Organize Medical Records: Collect, assemble, and file resident charts including nurses' notes, lab reports, x-rays, and progress notes to ensure all documentation is complete, accurate, and filed per facility policy. Ensure Compliance and Privacy: Safeguard resident information in accordance with HIPAA and facility confidentiality policies; maintain a log of all authorized record releases. Support MDS and Assessments: Assist the MDS Coordinator in scheduling and preparing assessments in line with OBRA and facility guidelines. Data Entry and Record Retrieval: Input resident demographic and clinical data into the system, retrieve and deliver records as requested by authorized personnel, and track sign-outs of charts. Committee and Administrative Support: Perform secretarial duties for facility committees, compile records for review, and maintain meeting minutes. Supervise and Train Staff: Oversee assigned medical records staff, provide guidance, take disciplinary action when necessary, and ensure department compliance with policies. Regulatory and Consultant Coordination: Work with the Medical Records/Health Information Consultant to meet state and federal requirements and assist during audits or inspections. Monitor Safety and Equipment: Report equipment malfunctions, maintain a clean work area, ensure supplies are stocked, and immediately report unsafe or hazardous conditions. Communication and Interdepartmental Collaboration: Maintain effective communication with nursing, administrative, and interdepartmental teams to support accurate and timely recordkeeping. Administrative Accountability: Assume full responsibility for assigned duties, maintain census data and reports, attend required trainings (OSHA, HIPAA, etc.), and perform other tasks as assigned.



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