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Medical Records Director
3 months ago
**Santa Anita Convalescent Hospital is hiring for a full-time Medical Records Director**
**Summary**: The Medical Records Director has responsibility for the initiation, maintenance and filing of resident records in the facility. The Medical Record Director has access to all Protected Health Information in the resident's charts.
**Essential Duties and Responsibilities**:
1. Demonstrates commitment to company’s mission, values and standards of ethical behavior.
2. Models a positive and professional image that emulates the organization's mission and encourages a spirit of cooperation with co-workers. Provides assistance to co-workers and promotes teamwork by sharing information useful to achieving desired results.
3. Complies with all company and departmental policies and procedures.
4. Coordinates and prepares medical record for new admission. Checks for completion of required data to meet Licensing and Certification requirements, and facility policies and procedures.
5. Assembles new admission registers and indexes and codes diagnoses.
6. Conducts in-house record monitoring of documentation requirements according to the audit and quality assurance system and schedules established by the facility. Completes special needs audit as required.
7. Develops procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.
8. Assures that medical records taken from the department are signed out and signed in upon return to the department.
9. Completes medical record thinning and filing on a regular basis. Files active and inactive records in accordance with established policies.
10. Reviews physician Progress Notes for additional diagnoses, indexes, and codes diagnosis.
11. Monitors timely completion of Medicare certifications and re-certifications.
12. Answers requests for information and subpoenas, following HIPAA and California Confidentiality of Health Information Act requirements for confidentiality and release of information.
13. Assembles and analyzes discharge records; obtains discharge summary for each discharge record, follows up as indicated.
14. Serves on the disaster team and assists Charge Nurse with tagging and preparing emergency records and information to be sent with the resident.
15. Reports the following in accordance with established facility procedures and regulatory standards: accidents and incidents; resident grievances, complaints, allegations of resident abuse and/or misappropriation of resident property; occupational exposure to blood, body fluids, infectious materials, and hazardous chemicals; concerns and suspected incidences of non-compliance including but not limited to hazardous conditions and equipment.
16. Ensures adherence to state and federal regulations and company policies and procedures; HIPAA confidentiality standards of resident and facility information; Infection Control, Universal Precautions, OSHA and safety standards; established safety precautions and regulations in the performance of tasks and the use of equipment and supplies.
17. Oversees the planning, developing, and directing of department. Sets departmental standards, develops departmental objectives and constantly strives to improve procedures. Reviews department policies, procedures, and manuals on a regular basis and makes or recommends changes. Assists in standardizing methods by which work will be accomplished and quality will be evaluated.
18. Assumes responsibility for selecting, training, directing and motivating competent department personnel. Leads team and provides proactive support, removing obstacles and providing solutions as needed. Evaluates employee performance, and provides input concerning wage and salary adjustments, counseling and disciplinary actions, termination, transfers, etc.
19. Demonstrates knowledge of facility and departmental quality improvement activities and/or participates in quality improvement meetings. Recommends any equipment and supplies needed for the department as well as any departmental improvements. Confers with department personnel to solicit input on improving service and addressing problem areas.
20. Makes written or oral reports and recommendations to Administrator concerning operation of department and in response to concerns or complaints.
21. Keeps abreast of current federal and state regulations, as well as professional standards, and makes recommendations on changes in policies and procedures to Administrator. May participate in workshops and seminars to stay current with changes in field, as well as to maintain professional status.
22. Maintains reference material necessary for complying with current standards and regulations, and that will provide assistance in maintaining quality service.
23. Performs other related duties as required.
The above listing of duties and responsibilities is not intended to be all-inclusive but rather to serve as a description of the range of duties and general nature of t
