Job Description
Job Description
Job Description
Position Overview
- The Medical Records Director (Non-Nurse) is responsible for overseeing the management of patient clinical records, which includes coding, auditing, and educating staff on recordkeeping practices in compliance with relevant laws, regulations, and organizational standards. This role also serves as the appointed Privacy Officer for the facility.
- This position reports directly to the Executive Director (ED).
Qualifications and Experience
- A Bachelor’s degree or an equivalent mix of education and experience is required.
- Must hold credentials as a Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT), or possess a degree in a health-related field with significant training and proven expertise in health information management.
- Experience in managing health information in post-acute care settings is essential.
Key Requirements
- Possess a thorough understanding of state and federal regulations regarding documentation, confidentiality, and legal matters related to health information.
- Exhibit proficiency in utilizing complex software systems effectively.
- Have a solid foundation in the relevant field of practice.
- Ability to make independent decisions when necessary.
- Familiarity with medical records practices and the laws, regulations, and guidelines that govern these functions in post-acute care environments.
- Implement and interpret the objectives, policies, and procedures of the medical records department.
- Demonstrate proficiency in all competency areas, including but not limited to medical coding, auditing, clinical records management, privacy responsibilities, supervisory duties, patient rights, and safety protocols.
- Maintain confidentiality regarding all proprietary and sensitive information.
- Adhere to organizational policies, including those related to harassment and compliance.
- Exhibit integrity and professionalism by following the organization’s Code of Conduct and completing required compliance training.
- Foster a culture of integrity, maintain an open-door policy, and ensure no retaliation against individuals who report concerns in good faith.
- Actively support the compliance program and Code of Conduct, ensuring full participation from department staff.
Core Responsibilities
- Conduct audits and ongoing reviews of all patient clinical records to ensure compliance with documentation and performance standards.
- Manage the filing systems for current, overflow, and discharged records.
- Act as the facility’s Privacy Officer to ensure HIPAA compliance.
- Understand and apply long-term care payment systems, including Medicare.
- Utilize ICD-10-CM coding effectively.
- Employ CPT/HCPCS coding systems as needed.
- Communicate effectively with physicians, nursing staff, and allied health professionals.
- Recruit, train, evaluate, counsel, and supervise the medical records team.
- Provide excellent customer service and maintain a positive demeanor towards patients.
- Assist in patient evacuation procedures when necessary.
- Demonstrate reliable and consistent attendance.
- Utilize reasoning skills and sound judgment in decision-making.
- Collaborate productively within an interdisciplinary team.
- Engage in various physical activities such as sitting, standing, bending, lifting, pushing, pulling, stooping, walking, reaching, and moving intermittently throughout the workday.
- Read, write, speak, and comprehend the English language proficiently.
- Ability to lift 35 lbs from floor to waist, from waist to shoulder, carry 35 lbs, and push/pull 35 lbs as required.
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