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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 establishment and upkeep of resident medical records in accordance with organizational standards and regulatory requirements. This role involves managing operations across all facilities under The Orchards umbrella, ensuring compliance with both state and federal guidelines.

Key Responsibilities:

  1. Collaborate with various departments to fulfill assigned duties and responsibilities.
  2. Examine medical records for accuracy and completeness, ensuring compliance with HIPAA and relevant laws.
  3. Stay informed about documentation standards and relay necessary information to team members.
  4. Provide authorized personnel with medical record data and prepare statistical reports accurately and promptly.
  5. Engage in professional development activities to remain updated on industry advancements.
  6. Guarantee that all medical records management processes adhere to applicable regulations while maintaining confidentiality.
  7. Supervise the collection and organization of information for resident charts, ensuring proper filing according to established systems.
  8. Review care plans and documentation for thoroughness and accuracy.
  9. Follow protocols for the retention, maintenance, and disposal of records.
  10. Conduct audits of medical documentation for admissions, readmissions, and discharges as directed.
  11. Compile Quality Improvement data as needed and communicate findings to relevant management.
  12. Maintain a log of resident admissions and discharges, ensuring records are filed correctly.

Additional Duties:

  1. Interact with residents, families, and staff in a respectful and supportive manner.
  2. Participate in necessary staff meetings and training sessions.

Supervisory Role:

Oversee the Medical Records Assistant and Clerk/Receptionist.

Qualifications:

To excel in this position, candidates must demonstrate proficiency in the essential duties outlined. The following qualifications are essential:

  • Education: Completion of a medical terminology program from a recognized institution; minimum of two years' experience in a healthcare setting; or a combination of education and experience.
  • Experience: At least one year of direct involvement in medical records or health information management.
  • Skills: Proficient in filing systems, understanding of medical documentation, and ability to interpret regulatory guidelines.
  • Computer Proficiency: Familiarity with software for managing resident information and generating reports.

Physical and Mental Requirements:

Employees must be able to perform essential functions, which may include walking, sitting, and standing for extended periods. The role may involve lifting light office supplies and requires visual acuity for processing documentation.

Work Environment:

Employees may encounter various conditions, including exposure to cleaning agents and the potential for contact with infectious materials. The noise level may vary from quiet to moderate, depending on the work area.

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