POSITION SUMMARY:

The Medical Records Director assumes authority,responsibility and accountability for the record keeping procedures and storageof all clinical records in a manner consistent with facility policies andprocedures, professional standards and county, state and federal laws andregulations, as applicable, for long term care facilities. Establishes and implements policies to ensurethat records are complete, accurately documented, readily accessible andsystematically organized.

QUALIFICATIONS/REQUIREMENTS:

• Education: High School graduate or equivalent
• Work Experience: 

  At least on year of clericalexperience, including filing
  Experience as a medical records practitioner in long term care facilitypreferred
  Ability to type, calculate and perform data entry skills

ESSENTIAL JOB FUNCTIONS:

• Perform health record maintenance duties;assembling, labeling, cleaning, filing and purging documents
• Keys information into computer systems,including EMR
• Maintain stock of forms and record supplies
• Request necessary resident information fromtransferring facilities
• Process external information requests fromauthorized institutions and individuals
• Compilestatistical data at the direction of Administrator
• PrepareAlirts (OSHPD) yearly report
• Maintainthe confidentiality and physical security of health records in accordance withHIPPA rules and regulationS
• Performconcurrent and discharge quantitative audits of health records. Physician visit audits. Notification of physician when required byprocedure
• Developand perform specialized audits on a predetermined time sequenced rotation withplan of completion to be defined and time limited. Audit all current resident charts to notatedeficiencies and obtain and assist in corrections on a scheduled basis. Submit deficiency reports and to personsresponsible for correction with date of completion to be returned (3 days) tothe Administrator, Director of Nurses or designated representatives. 
• Diseaseindex coding at time of admission, when diagnostic status alters and within 30days of discharge date. Complete anyoutstanding disease index coding
• Dischargecharts must include the following information prior to filing:
a. Final Diagnosis and/or Death Certificate
b. CompletedDisease Index Coding
c. Obtain all outstanding documentation andrequired signatures to meet criteria mandated by facility policy.
• Mailtelephone order forms to physicians daily, assure prompt return and file inchart
• PreparePhysician Orders, Medication/Treatment records, ADL records and Resident CarePlans for accurate input into computer and printing on scheduled basis
• Performcomputer operation functions including regular input of data and printing on ascheduled basis
• Keepcomputer terminal(s), keyboard(s) and office clean and functional
• Maintainappropriate medical record storage and destruction of medical recordsconsistent with facility policy
• Follow-upon reports and recommendations submitted by the Medical Records Consultants andService Center Medical Records Analysts
• Reportto the Director of Nursing and Administrator significant documentation problems
• Attendand participate in in-service education and staff meetings as required,including risk management and daily stand-up meetings. Maintain minutes of meetings/files asrequested
• Becourteous, considerate and cooperative when communication with all facilitypersonnel, resident and public
• Reactappropriately to emergencies and disaster situations

JOBFUNCTIONS:

• Demonstrateknowledge of, and respect for, the rights, dignity and individuality of eachresident in all interactions
• Appreciatesthe importance of maintaining confidentiality of resident and facilityinformation
• Demonstratehonesty and integrity at all times in the care and use of resident and facilityproperty
• Mustbe able to key information into computer systems
• Ableto understand and to follow written and/or verbal directions. Able to express self adequately in oraland/or written communication. Able tocommunicate effectively with staff members, other professional staff,consultants and residents
• Demonstratesability to prioritizetasks/responsibilities and complete duties/projects within allotted time
• Ableto respond to change productively and to handle additional tasks/projects asassigned
• Ableto carryout the essential functions of this job (with or without reasonableaccommodation) without posing specific, current risk of substantial harm to healthand safety of self and others
• Otherduties as assigned by the Administrator