SUMMARY

The primary purpose of your job position is to plan, develop, organize, implement, and direct Medical Records staff in accordance with current and existing Federal, State, and Local standards, as well as our established policies and procedures to ensure that a complete medical records program is operating effectively and is being maintained properly.

ESSENTIAL RESPONSIBILITIES AND JOB FUNCTIONS

1. Plan, develop, organize, implement, and direct Medical Records staff in the overall medical records function in the facility.

2. Establish procedures to be followed in the collection, coding, indexing, and filing/retrieving of medical records.

3. Review discharge and death records, as well as nursing unit records in a private office setting.

4. Refer incomplete medical records/charts back to the nursing department for correction.

5. Ensure medical records are properly assembled, coded, signed, and indexed prior to filing.

6. Ensure medical records clerks maintain a record authorizing information taken from the medical records/charts.

7. Manage the medical record request process.

8. Prepare medical records for subpoena requests.

9. Meet with Administration and other facility management personnel on medical records issues that requires the input of other departments.

10. Develop and maintain a good working rapport with other departments to ensure that the medical records program is properly maintained and meets the needs of the residents and facility.

11. Develop and implement department policies and procedures.

12. Keep abreast of current Federal and State regulations and recommend necessary changes as needed.

13. Review departmental policies and procedures and recommend changes periodically.

14. Develop and manage a departmental budget and monitor expenditures.

15. Serve on various committees of the facility as appointed by the Administrator.

16. Develop training and inservice programs that can be used by medical records staff members.

17. Provide direction to Medical Records staff members when dealing with problematic situations.

18. Compile and maintain a departmental schedule.

19. Maintain confidentiality of all pertinent patient care information housed in the Medical Records office.

20. Review complaints and grievances and make recommendations to the Administrator.

21. Ensure that the Medical Records department has the necessary equipment and supplies to operate effectively.

EDUCATION/EXPERIENCE

To perform this job successfully, an individual must be able to fulfill each essential duty with a strong degree of professionalism. This position requires a detail-oriented professional with excellent communication skills. The requirements listed below are representative of the knowledge, skill and/or ability required.

· Must minimally possess a High School Diploma.

· Medical Records management experience in a Long-Term care setting.

· Medical Records Certification from an accredited program.

LANGUAGE/REASONING AND INTERPERSONAL SKILLS

· Must possess ability to speak, read and write English effectively.

· Must possess emotional maturity, reliability, tact, integrity, and good judgment.

· Must possess an understanding of facility’s goals and philosophy.

· Must possess good problem solving skills with ability to plan, organize, and execute work activities independently.

· Must possess ability to interact effectively with team members, residents, families and visitors.

· Must possess knowledge of accreditation and licensing standards as they apply to resident care and safety.

PHYSICAL DEMANDS/WORK ENVIRONMENT

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

· The physical demands and work environment described herein is representative of those that generally 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.

· Work primarily involves standing, walking, twisting, reaching, bending/stooping, as it relates to standard office activity.

· Vision abilities required by this job includes good vision and depth perception, both near and far as well as ability to distinguish basic shades and colors.

· The noise level in the facility work environment is usually moderately quiet; however, at times, due to the nature of clients treated at this facility, occasional loud outbursts by residents may be expected.

· The employee is required to hear within normal range and at a conversation level.

· The employee is required to have the ability to express or exchange ideas frequently and the ability to understand communication of others with or without adaptive devices.

· This position requires performing simple repetitive tasks regularly and performing complex or varied tasks often.

· This position requires that employee have the ability to make generalizations, evaluations or decisions using independent judgment without immediate supervision.

· This position requires the employee to work minimally 8 hours per day, five days per week. Additional hours and days may be necessary to ensure adequate operations of the facility.

· This position may require the use of a computer for up to 4-6 hours per day.

DISCLAIMER

The above information on this job description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.