Medical Records Director

Summary

Supervises the creation and maintenance of resident’s medical records according to The Orchards guidelines and in compliance with state and federal regulations by performing the following duties on site in the Chester campus but will oversee all Orchards locations.

Essential Duties and Responsibilities:

1. Teamwork with the following and all other duties and responsibilities assigned.

2. Reviews medical records for completeness for release in accordance with HIPPA and all other federal and state laws/regulations.

3. Stays current with documentation requirements for medical records and communicates requirements to staff.

4. Provides medical record information to authorized personnel as required and prepares statistical reports as required neatly, timely and accurately.

5. Participates in professional activities and organizations to keep abreast of technical developments and their applications.

6. Ensures that all aspects of the medical records management process meet applicable regulatory requirements and always maintains confidentiality of all resident information.

7. Supervises the collection of all information required for a resident's chart, arranges charts in proper sequence, and files records in designated areas according to alphabetic or numeric filing systems.

8. Reviews residents care plans and RN/C.N.A. flow sheets for completeness.

9. Follows established guidelines for retaining, maintaining, and purging records.

10. Reviews charts to ensure that new forms, doctor physicals, laboratory test records, progress notes, signatures, etc. are complete and current. Maintain records of residents.

11.Gathers and compiles Quality Improvement data as requested from the Director of Nursing. Communicates any deficiencies to the Director of Nursing and the Administrator.

12. Conducts documentation audits on admission, readmission, and discharges as directed by the Director of Nursing.

13. Conducts qualitative and quantitative analysis of admissions, discharges, transfers, and re-admissions as requested by the Director of Nursing. Files records accordingly. Maintains resident’s admissions and discharge log.

Other Responsibilities:

1. Interacts with residents, families, and employees in a considerate, helpful and courteous manner.

2. Participates in staff meetings as necessary

3. Attend In-service Training Sessions as well as other meetings and training as required

or appropriate for the Medical Records Director position.

Supervisory Responsibilities

Medical Records Assistant, Clerk/Receptionist

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

One year certificate in medical terminology from a technical school; requires at least two years of experience in a medical environment; or equivalent combination of education and experience; and at least one year of direct experience in medical records or health information. Complete annual state mandated training requirements (Regular In-services as well as any external training).

Language Skills

Ability to file records according to a recognized alphabetic system. Ability to read and interpret documents, including but not limited to: governmental regulations and publications as they pertain to the maintenance of medical records; charts, forms, logs, and notes from internal and external medical staff; safety rules; operating and maintenance instructions for office equipment; and corporate policies and procedures. Ability to write reports of Quality Improvement data. Ability to present information and respond to requests from internal and external medical staff, residents and their family members, and management.

Mathematical Skills

Ability to file records according to a recognized numerical system. Ability to add, subtract, multiply, and divide in all units of measure, including whole numbers, common fractions, and decimals when determining supply needs and placing supply orders.

Reasoning Ability

Ability to solve practical problems and deal with several concrete variables in standardized situations, such as maintaining or purging resident records, auditing files and tracking down missing data, following medical record filing guidelines and regulations, and preparing statistical reports. Ability to interpret a variety of written and verbal instructions. Ability to create and/or read work schedules, calendars of events, class schedules, and appointment schedules.

Computer Skills

Uses the computer to maintain resident chart information to be included in the records and to gather data for various reports. Uses e-mail to communicate with others internally and externally. Individual should also have knowledge of spreadsheet and word processing software for creating reports, correspondence, and schedules.

Certificates, Licenses, Registrations

None required.

Other Skills and Abilities

Skills specific to communicating with geriatric residents are needed. Ability to read and understand medical terminology.

Medical Screenings

Physical and Tuberculosis testing are required annually.

Mental Abilities

* The ability to get along with others

* The ability to concentrate for extended periods of time

* The ability to shift focus from one task to another

* The ability to prioritize tasks effectively

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to walk throughout the campus; sit at a desk or conference table; and talk or hear when interacting with various individuals. The employee is occasionally required to stand while filing records or conversing with various individuals; use hands to finger, handle, or feel when using the computer or telephone or manipulating files and other office equipment and supplies; reach with hands and arms for files, forms, and binders; and stoop, kneel, or crouch to communicate with residents and to place items in or get items from low drawers or shelves. The employee must occasionally lift and/or move up to 25 pounds, which is generally office supplies such as boxes of paper, files, and forms. Specific vision abilities required by this job include close vision for processing and filing paperwork and working on the computer; color vision for reading color-coded spreadsheets or documents; and the ability to adjust focus from the computer to the desk or office area.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally exposed to fumes from medications or cleaning supplies; and extreme heat due to keeping residents comfortable at warm temperatures. The employee may be exposed to airborne viruses, bacteria, and other bodily pathogens carried by residents. The noise level in the work environment can range from quiet while in the file rooms to loud when in resident common areas where there are televisions and equipment operating, phones ringing, light to heavy traffic, and people talking.

Job descriptions represent a general outline of job duties, functions, and qualifications. They are not intended to be comprehensive in nature. In addition, jobs evolve over time and therefore their description may not reflect the precise nature of the position at a given point in time.

It is The Orchards of Saxonburg’s policy to base hiring decisions solely on the individual’s ability to perform essential job functions. Persons with disabilities are eligible for this position provided they can perform those functions with reasonable accommodation.

I have read the Medical Records Specialist job description. By my signature I confirm that I fully understand and certify that I am able to perform the duties listed.

The Orchards is an Equal Employment Opportunity Employer and does not discriminate against applicants or employees on the basis of race, color, religion, creed, national origin, ancestry, disability that can be reasonably accommodated without undue hardship, sex, sexual orientation, gender identity, age, citizenship, marital or veteran status, or any other legally protected status.