Head of Medical Records Management

2 weeks ago

Alliance, Ohio, United States The Orchards Full time
Job Overview

Position Summary

The Director of Medical Records is responsible for overseeing the establishment and upkeep of resident medical documentation in alignment with organizational standards and in adherence to state and federal regulations. This role is pivotal in ensuring compliance across all locations within the organization.

Key Responsibilities:

  1. Collaborate with various departments and undertake additional responsibilities as assigned.
  2. Evaluate medical records for accuracy and completeness, ensuring compliance with HIPAA and relevant laws.
  3. Stay informed about documentation standards and relay this information to the team.
  4. Provide necessary medical record data to authorized personnel and generate required statistical reports in a timely and precise manner.
  5. Engage in professional development activities to remain updated on technical advancements and their implications.
  6. Guarantee that all medical records management processes adhere to applicable regulations while maintaining the confidentiality of resident information.
  7. Supervise the collection and organization of all necessary information for resident charts, ensuring proper filing according to established systems.
  8. Review care plans and related documentation for thoroughness.
  9. Adhere to established protocols for record retention, maintenance, and disposal.
  10. Inspect charts to confirm that all forms, physicals, lab results, and notes are current and complete.
  11. Compile Quality Improvement data as requested and communicate any issues to relevant management.
  12. Conduct audits of documentation during admissions, readmissions, and discharges as directed.
  13. Perform qualitative and quantitative assessments of admissions and discharges as required, maintaining accurate logs.

Additional Duties:

  1. Engage with residents, families, and staff in a respectful and supportive manner.
  2. Participate in necessary staff meetings.
  3. Attend training sessions and meetings relevant to the role.

Supervisory Responsibilities:

Oversee the Medical Records Assistant and Clerk/Receptionist.

Qualifications:

To excel in this position, candidates must demonstrate the ability to perform essential duties effectively. The following qualifications are essential:

  • Completion of a one-year certificate in medical terminology from a recognized institution; a minimum of two years of experience in a medical setting; or a combination of education and experience, including at least one year of direct involvement in medical records or health information.
  • Ability to interpret and manage documentation in accordance with regulatory standards.
  • Proficiency in using computer systems for record maintenance and report generation.

Skills:

Strong communication skills, both verbal and written, are necessary for interacting with various stakeholders. The ability to analyze and solve practical problems is crucial for maintaining compliance and ensuring the integrity of medical records.

Physical and Work Environment:

This role requires regular movement throughout the facility, with occasional lifting of supplies. The work environment may include exposure to various elements typical of a healthcare setting.

The Orchards is committed to equal employment opportunities and does not discriminate based on any protected status.

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