Job Description
Position Summary
- The Medical Records Director (Non-Nurse) maintains the patients’ clinical records, including coding, auditing, and providing pertinent staff education regarding recordkeeping procedures in accordance with all applicable laws, regulations, and Life Care standards. Serves as the designated Privacy Officer for the facility.
- Reports to Executive Director (ED)
Education, Experience, and Licensure/Certifications
- Bachelor’s degree OR an equivalent combination of education and experience
- Credentialed as a Registered Health Information Administrator (RHIA) OR as a Registered Health Information Technician (RHIT) OR have a degree in a health related field with extensive training and demonstrated competence in the HIM field
- Training in post-acute care health information management
Specific Requirements
- Demonstrate knowledge of State and Federal legal requirements relating to documentation, confidentiality, and legal issues pertaining to health information
- Demonstrate efficient usage of complex computer software systems
- Functional knowledge in field of practice
- Make independent decisions when circumstances warrant such action
- Knowledgeable of medical records practices and procedures as well as the laws, regulations, and guidelines governing medical records functions in the post-acute care facility
- Implement and interpret the programs, goals, objectives, policies, and procedures of the medical records department
- Perform proficiently in all competency areas including but not limited to: medical coding, auditing, clinical records, privacy official responsibilities, supervisory responsibilities, patient rights, and safety and sanitation
- Maintains confidentiality of all proprietary and/or confidential information
- Understand and follow company policies including harassment and compliance procedures
- Displays integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training
- Promotes a culture of integrity, maintains an “open door” policy, and does not participate in or allow retaliation against those who report good faith concerns
- Actively implements the compliance program and Code of Conduct and ensures 100% participation by department staff
Essential Functions - Audit and complete ongoing review of all patients’ clinical records to ensure documentation and performance compliance
- Maintain current, overflow, and discharged record filing systems
- Serve as the facility’s Privacy Officer for HIPAA compliance
- Understand and apply LTC payment systems, including Medicare
- Use ICD-10-CM coding
- Use CPT/HCPCS coding systems
- Effectively communicate with physicians, nursing staff, and allied health personnel
- Interview, hire, train, evaluate, counsel, and supervise medical records staff
- Exhibit excellent customer service and a positive attitude towards patients
- Assist in the evacuation of patients
- Demonstrate dependable, regular attendance
- Concentrate and use reasoning skills and good judgment
- Communicate and function productively on an interdisciplinary team
- Sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
- Read, write, speak, and understand the English language
- Must be able to lift 35 lbs floor to waist, lift 35 lbs waist to shoulder, lift and carry 35 lbs, and push/pull 35 lbs
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