Reports to: Administrator

Department: Administrative

Purpose of Your Position:

The primary purpose of your job is to maintain medical records in accordance with federal and state guidelines, as well as in accordance with our established policies and procedures, to assure that a complete medical records program in maintained.

Delegate of Authority:

As Medical Records Director, you are delegated the administrative authority, responsibly, and accountability necessary for carrying out your assigned duties.

Job Functions:

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Duties and Responsibilities

Administrative Functions:

Quality Monitoring and Quality Assurance Functions:

Participate in the facility Quality Assurance Committee and process:

• Maintain security of health information systems and medical records. Assure physical protection is in place to prevent loss, destruction and unauthorized use and disclosure of both manual and electronic records. For example, assure that safeguards are in place such as sign-out systems, assignment of computer passwords/log-ons, and systems for securing file cabinets and file rooms where overflow and discharge records are stored;
• Assure systems are in place to maintain confidentiality of both manual and electronic health information;
• Manage the release of information functions for the facility, including review and processing of all requests for information. Maintain facility policies and standards of practice to assure release of information requests are appropriate and meet legal standards;
• Maintain a forms management system for development, review, and reproduction of facility forms. Maintain a master forms files/manual
• Assist physicians, visitors;
• Answer telephones when needed.Maintain a quantitative/qualitative audit/monitoring process;
• Collect data and report findings to QA Committee;
• Conduct routine monitors (admission, MDS, concurrent, acute problems, and discharge) and perform focused reviews of problem areas, QA concerns, Quality Indicators and survey issues.

Health Information Management Functions:

Computerization/Automation:

Understand all aspects of clinical computer system;

• Maintain the security of the system by assuring that audit trails and password security are in place.
• Monitor audit trails and follow-up on possible breaches in confidentiality/security;
• Assure systems are in place to maintain up to date resident-specific information in the clinical information system.
• Complete data entry functions as applicable;

Records Management Functions:

• Admissions:
• Work in conjunction with the admissions coordinator to ensure completion of all aspects of the admission process;
• Complete the appropriate information in the census register (if applicable);
• Complete and file as applicable the master index information (computerized or manual);
• Initiate the in-house medical record and in-house overflow file, prepare labels, etc.;
• Complete admission checklists and admission monitors;
• During the Resident’s stay:
• Ensure that each resident has a current payer sourc.
• Act as a liaison to the billing company, forward required documentation, 
• Complete non-covered services forms and maintain records for easy retrieval, forward to the billing company;
• Coordinate with Social Services regarding completion of applications, e.g. Medi-Cal redetermination papers and other needed required documents;
• Act as a liaison between Nursing, ancillary disciplines and the Health Information Department;
• Contact physicians or departments as needed when signatures or information is needed before records can be completed;
• Ensure that physicians are completing Medicare certifications/re-certifications;
• File all incoming clinical information in the in-house records on a daily basis;

Discharge:

• Record appropriate discharge information in the census register (if applicable);
• Monitor and Follow-up on discharge record deficiencies including monitoring/mailing information to the physician for completion as applicable. Maintain discharge record control log. File discharge record in incomplete clinical record file until complete and then, file the discharge record in the complete file;

Billing Management Functions:

Understand all aspects of billing process for all payer types.

Review & Mail out PrivateStatements.

Post ancillary charges

Participate in tripe Check for Medicare and Managed Care Billing

Understand collecting process for all payers’ types.

Communicate with Residents/Family as needed.

Complete facility statistical reports such as monthly facility statistics, daily census, licensure reports as applicable;

Communicate with our billing company;

Communicate with Social Services Office, Medi-Cal and MediCare offices as needed;

Communicate with Insurance companies, HMOs;

Communicate with pharmacy, laboratory, X-ray, Hospice companies;

Participate in meetings and committees such as daily stand-up, administrative, quality assurance/quality improvement, Medicare documentation review.

Committee Functions:

• Attend committees as assigned by the Administrator.
• Participate in the Safety Program

Personnel Function:

• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility and also with outside agencies.
• Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment.

Staff Development:

• Attend and participate in workshops, seminars, etc., as approved.
• Attend and participate in orientation, in-service educational classes and on-the-job training programs including annual OSHA and CDC in-service training programs concerning hazard communication, TB management, and bloodborne pathogens.

Safety and Sanitation:

• Follow established fire safety policies and procedures.
• Follow established safety precautions when performing tasks and when using equipment and supplies.
• Wear and/or use safety equipment and supplies (e.g., back brace, etc.) when lifting or moving heavy objects.
• Wear non-slip shoes as required.
• Practice infection control policies and procedures of the facility
• Ensure that assigned work areas are maintained in a clean, safe, comfortable, and attractive manner.
• Complete environmental safety checklists, quarterly.
• Report all unsafe/hazardous conditions, equipment, etc., to your supervisor immediately.
• Report any incident or accident per facility policy.

Equipment and Supply Functions:

• Report equipment malfunctions or breakdowns to your supervisor as soon as possible.
• Ensure supplies have been replenished in work areas as necessary.
• Assure that work/assignment areas are clean and records, files, etc., are properly stored before leaving such areas on breaks, end of work day, etc.

Residents Rights:

• Maintain confidentiality of all pertinent resident care information to assure residents rights are protected.
• Knock before entering a resident’s room.
• Ensure that resident’s rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints, are followed.

Working Conditions:

• Works in office areas as well as throughout the facility and its premises.
• Moves intermittently during working hours.
• In subject to frequent interruptions.
• In subject to hostile and emotionally upset residents, family members, visitors, etc.
• Works beyond normal working hours, week-ends and holidays, and on other shifts as necessary.
• In subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.)
• Attends and participates in continuing educational programs.
• Communicates with nursing, and other department personnel.
• Is subject to injury from falls, burns from equipment, odors, etc., throughout the work day, as well as reactions from dust, disinfectants, tobacco smoke, and air contaminants.
• In subject to pressure from multiple/emergency calls.
• In subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.
• May be subject to the handling of and exposure to hazardous chemicals.

Educational Requirements:

• Must possess, as a minimum, a high school diploma.

Experience:

• Must be able to type a minimum of 35 words per minute, use office equipment, and have a working knowledge of medical terminology.
• On-the-job training provided in medical records procedures.

Specific Requirements:

• Must be able to read, speak, and understand the English language
• Must possess the ability to make independent decisions when circumstances warrant such action and to remain calm during emergency situations.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, and the general public.
• Must be knowledgeable of medical terminology.
• Must possess the ability to work harmoniously with other personnel.
• Must possess the ability to minimize waste of supplies, misuse of equipment, etc.
• Must possess the ability to seek out new methods and principles and be willing to incorporate them into existing practices.
• Must be able to follow written and oral instructions.
• Be knowledgeable in computers, data input and output.
• Must not pose a direct threat to health or safety of the individual in the workplace.

Physical and Sensory Requirements (with or without the Aid of Mechanical Devices)

• Must be able to move intermittently throughout the workday.
• Must be able to speak and write English language in an understandable manner.
• Must be able to cope with the mental and emotional stress of the position.
• Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
• Must meet the general health requirements set forth by the policies of this facility that include a medical examination.
• Must function undependably, have flexibility, personal integrity, and the ability to work effectively with other personnel.
• Must have pleasant speaking voice.
• Must be able to push, pull, move, and/or lift a minimum of 25 pounds to minimum height of 3 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 10 feet
• May be necessary to assist in the evacuation of residents during emergency situations