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Medical Records Director

2 months ago

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

Position Summary

The Medical Records Director is responsible for overseeing the development and upkeep of resident medical records in accordance with organizational standards and relevant legal requirements. This role is pivotal in ensuring that all medical documentation is accurate, complete, and accessible across all Orchards locations.

Key Responsibilities:

  1. Collaborate with various departments to fulfill additional duties as assigned.
  2. Examine medical records for accuracy and completeness, ensuring compliance with HIPAA and other applicable regulations.
  3. Stay informed about the latest documentation standards and relay these updates to the team.
  4. Provide necessary medical record information to authorized personnel and generate statistical reports as needed.
  5. Engage in professional development activities to remain updated on industry advancements.
  6. Guarantee that all medical records management practices adhere to regulatory standards while maintaining confidentiality.
  7. Supervise the assembly of all required information for resident charts, ensuring proper organization and filing.
  8. Review care plans and documentation from nursing staff for thoroughness.
  9. Adhere to established protocols for record retention and disposal.
  10. Ensure that all medical forms and documentation are current and properly filed.
  11. Compile Quality Improvement data as requested and communicate any issues to the nursing director and administration.
  12. Conduct audits of documentation during admissions, readmissions, and discharges as directed.
  13. Perform qualitative and quantitative assessments of resident transitions and maintain 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 other relevant meetings to enhance skills pertinent to the Medical Records Director role.

Supervisory Role:

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:

  1. Completion of a medical terminology certificate program and a minimum of two years of experience in a healthcare setting, or an equivalent combination of education and experience, including at least one year in medical records or health information.
  2. Ability to interpret and manage various documentation, including governmental regulations and internal policies.
  3. Proficiency in filing systems and the ability to generate reports based on Quality Improvement data.
  4. Competence in basic mathematical operations for inventory and supply management.
  5. Strong problem-solving skills and the ability to manage multiple tasks efficiently.
  6. Familiarity with computer systems for maintaining resident information and generating reports.

Physical and Mental Requirements:

This role requires the ability to interact with residents and staff, manage documentation efficiently, and maintain focus on tasks for extended periods. Physical demands include walking, sitting, and occasional lifting of supplies.

Work Environment:

The work environment may involve exposure to various conditions typical of a healthcare setting, including noise and potential exposure to health-related risks.

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