SUMMARY OF JOB:

The Director of Medical Records assumes authority, responsibility, and accountability for the record keeping procedures and storage of all clinical records in a manner consistent with facility policies and procedures, professional standards and state and federal laws and regulations for long term care facilities. Manages employees in Medical Records Department. Establishes and implements policies to ensure that records are complete, accurately documented, readily accessible and systematically organized. Collaborates with Nursing Home Administrator to allocate department resources in an efficient and economic manner to achieve department objectives.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

1. Responsible for coding all diagnoses on the resident’s medical record for all admissions and subsequent treatments according to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) official coding guidelines. Update codes on resident’s diagnosis list in the electronic medical record (EMR) system to ensure consistency within the clinical record.
2. Review PASRR forms for accuracy and completeness.
3. Initiates and participates in the development of facility policies and procedures to ensure that medical records are complete, accurately documented, readily accessible and systematically organized.
4. Develops and implements record storage and retrieval system that complies with applicable record retention laws and maintains accessibility of records.
5. Develops, implements, and maintains appropriate safeguards against lost, destruction, unauthorized access or use of resident’s protected health information (PHI) including procedures to maintain confidentiality/privacy of all information contained in the resident’s paper and electronic medical record.
6. Manage the release of health information functions for the facility including reviewing and processing all request for PHI. Maintain facility policies and standards of practice to assure release of information requests are appropriate and meet legal regulations. Consult with Nursing Home Administrator, Executive Director and facility’s attorney as needed.
7. Conduct qualitative and quantitative audits of open and closed records to ensure compliance with medical record documentation policies. Maintains audit system according to policy and procedures to assure completeness, accuracy, and internal consistency. Obtain complete and accurate records within established timeframes. Report findings to Nursing Home Administrator and Director of Nursing (DON), if applicable.
8. As requested, participate in the development of departmental budget. Provides relevant information to Nursing Home Administrator regarding department financial needs and status.
9. Manage human resource functions for the medical records department including interviewing, hiring, staff scheduling, assigning and reviewing work performance, perform annual work performance evaluations, and enforcing disciplinary actions.
10. Provide initial and annual training to unit clerks on topics such as medical record organization and content, record completion, confidentiality/privacy, documentation standards and error correction procedures.
11. Supervise unit clerk duties and conduct periodic quality control assessments to assure staff competency and performance. Analyze findings and develop and implement ways to improve performance.
12. Conducts medical records department meetings with unit clerks to maintain two-way communication, problem solving, information dissemination, and feedback.
13. Provide guidance, motivation, and support to the unit clerks.
14. Maintains current policies and procedures and job descriptions for the medical records department.
15. Prepares open and closed charts for state review.
16. Actively participates in state survey process by instructing unit clerks in manner of conduct and disclosure; maintain a presence while surveyors are on-site and directing the timely collection of information required by the survey team. Collaborates with Nursing Home Administrator to develop responses to survey reports as needed.
17. Prepares open and closed charts for quarterly UMR team review.
18. Participate in facility quarterly QAPI meetings; collect and report data from audit findings to QAPI committee and develop action plan for identified problems/concerns.
19. Serve as a HIPAA resource for the facility
20. Manage the credentialing process for physicians and nurse practitioners.
21. Complete mandatory Relias Training.
22. Perform other duties assigned by the Nursing Home Administrator, as needed

EDUCATIONAL REQUIREMENTS:

• Associates or Bachelors degree from an accredited college or university required.
• Current certification as a Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).

EXPERIENCE/KNOWLEDGE/SKILLS:

• Two (2) years’ experience as a medical records practitioner, preferably in a long-term care facility.
• ICD-10-CM coding experience.

PHYSICAL AND ENVIRONMENTAL REQUIREMENTS:

• Light physical effort

o Lift/carry up to 20 lbs.

• Balance of sedentary/mobility work

o Occasional kneeling/stooping/crouching/reaching/bending

o Occasionally moves/lifts supplies or equipment

• Reading/seeing/writing requires far and near visual acuity, field vision, and color vision to read written communications
• Must be able to write legibly