What are the responsibilities and job description for the Medical Records Director position at Parkhouse Nursing and Rehab Center?
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 arecomplete, accurately documented, readily accessible and systematically organized. Collaborates with Nursing Home Administrator to allocate department resources in an efficient and economic manner toachieve department objectives.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Ensures that all clinical records contain sufficient information to identify the resident; a record of the resident’s assessments; the plan of care and services provided; the results of any pre-admission screenings conducted and required by the State and departmental progress notes.
Is responsible for all diagnostic disease and treatment coding for all admissions and subsequent treatments as reviewed by and communicated to Medical Records to ensure consistency within the clinical record, VistaKeane and RAM.
Conducts, at a minimum, quarterly disease code reviews in conjunction with the Interdisciplinary CareConference Team. Inputs any changes into RAM and ensures an updated copy is on the resident record.
WORK EXPERIENCE/EDUCATION REQUIREMENTS
Education: Associates or Bachelors degree from an accredited college or university required.
Certificate/Licenses: Current certification as a Registered Health Information Technician (RHIT) or Registered Health Information
Administrator (RHIA).
Work Experience:
One year experience as a medical records practitioner, preferably in a long-term care facility.
Freedom from illegal use of drugs, and freedom from use and effects of use of drugs and alcohol in the workplace.
Persons who have been found guilty by a court of law of abusing, neglecting or mistreating individuals in a health care related setting are
ineligible for employment in this position.
2. Specialized Knowledge & Skills: To perform the job successfully, an individual should demonstrate the following
competencies:
Working knowledge and ability to apply professional standards of professional medical records practice for long term care. Able to establishcriteria to ensure that records practices meet professional standards of quality.
Able to update, facilitate, promote the attainment of high quality content of medical records in accordance with facility policies andprocedures, consistent with state and federal laws and regulations applicable to long term care facilities. Knowledge of computer systems to complete these functions.
Current knowledge of state and federal laws and regulations that apply to management of medical records in long term care. Able to assure compliance with regulations as they relate to medical records and documentation.
Able to design and implement systems to manage health care information in long term care facilities which is used in the efficient and economic delivery of care and services to residents.
Able to provide systems for health data and medical record retrieval and retention that meets the needs of the facility, providers and theresidents.
Sufficient management skills to perform personnel and budget functions and to effectively utilize available resources in performing management and supervisory functions. Able to apply facility personnel policies to facts concerning employment actions without regard to race, religion, sex, age, national origin or disability.
Strong organizational and interpersonal skills to work effectively with all departments and Administration in management of medical records.
Able to understand and to follow written and verbal directions. Able to effectively communicate with staff members and residents through verbal and/or written means.
Able to express self adequately in written and/or oral communication and to communicate effectively in an interdisciplinary care setting with residents, families, staff members, representatives of community and government agencies.
Carries out all duties in accord with the facility mission and philosophy.
Demonstrates knowledge of and respect for the rights, dignity and individuality of each resident in all interactions.
Able to design and implement records management system that ensures confidentiality of resident and protects residents against unauthorized disclosure of personally identifiable medical and social information.
Demonstrates honesty and integrity at all times in the care and use of resident and facility property.
Knowledge of emergency and disaster procedures of facility. Able to locate nearest exit, to understand and respond to written and oral instruction in case of emergency.
Sufficient mobility, and strength to move freely through the building, to assure resident safety at all times and to assist, transfer or otherwise move residents of facility out of danger in case of emergency.
WORK EXPERIENCE/EDUCATION REQUIREMENTS
Education: Associates or Bachelors degree from an accredited college or university required.
Certificate/Licenses: Current certification as a Registered Health Information Technician (RHIT) or Registered Health Information
Administrator (RHIA).
Work Experience: One year experience as a medical records practitioner, preferably in a long-term care facility.
Freedom from illegal use of drugs, and freedom from use and effects of use of drugs and alcohol in the workplace.
