KC- Director of Medical Records

McCrite Plaza•Kansas City, KS

About The Position

The Medical Records Clerk’s primary function is to compile, process, and maintain medical records of residents. Order, stock, deliver, and maintain supplies.

Requirements

Prior experience in a similar working environment is preferred, but not a requirement of the position.
Experience in health care is desired.
Ability to understand, observe, and enforce infection control procedures related to facility services.
Ability to observe all facility safety policies and procedures.
Ability to understand and recognize potential physical, chemical, and electrical hazards and take immediate corrective action as appropriate.
Ability to understand and enforce the Exposure Control Plan as this position risks occupational exposure to blood borne pathogens and other infectious material as an essential function of the job.
Ability to safeguard the privacy of Residents’ health information.
Ability to speak and read English and follow oral and written directions.
Ability to establish and maintain effective working relationships with the public, residents, and staff.
Ability to use computers; the ability to use the designated facility computer system (or systems) at a proficient level.
Ability to perform other related duties as directed by administration.
Must attend staff meetings, in-service classes, and committee meetings as assigned or required.
Ability to stand, stoop, crouch, kneel, balance, finger, grasp, push, pull, reach, or walk.
Ability to lift objects from a lower to higher position or moving objects along a horizontal level but from position to position. This includes lifting and carrying weights up to 75 pounds.
Ability to exert force upon an object in order to draw, drag or tug objects toward the source of the force in a sustained motion.

Responsibilities

Direct and maintain complete, accurate, and timely medical records for all residents
Assemble, audit, and monitor medical records for required documentation, signatures, and physician orders
Ensure records reflect the residents’ plan of care and support clinical decision-making
Maintain admission, discharge, transfer, and closed record processes
Ensure compliance with CMS regulations, HIPAA, and state long-term care requirements
Prepare and organize medical records for surveys, audits, and complaint investigations
Participate in state and federal surveys and respond to documentation requests
Maintain documentation systems in a constant state of survey readiness
Safeguard all protected health information (PHI)
Process medical record requests in compliance with HIPAA and facility policy
Maintain release-of-information logs and authorization forms
Ensure proper storage, retention, and destruction of records per regulatory standards
Oversee electronic and/or hybrid medical record systems
Ensure accurate scanning, indexing, and maintenance of electronic records
Collaborate with nursing, therapy, and ancillary departments to support documentation workflows
Train staff on proper documentation standards and medical record procedures
Conduct routine medical record audits to identify deficiencies and trends
Report audit findings and participate in corrective action planning
Support QAPI initiatives related to documentation accuracy and compliance
Supervise and train medical records staff, when applicable
Serve as a resource to interdisciplinary team members regarding documentation standards
Collaborate with nursing leadership, physicians, and department heads to resolve documentation issues
Assemble admission packets.
Process records when a resident is admitted.
Verify diagnoses and allergies with DON/ADON and/or other designated staff and record on admission record.
Ensure that all information is complete on admission record; place admission record in medical record; notify DON/ADON and/or other designated staff member when documentation is incomplete.
File medical records and review for completeness, accuracy, and compliance with state and federal regulations; within 24 – 48 hours initiate audit; complete form and follow-up with DON/ADON and/or other designated staff member within 72 hours.
Retrieve resident medical records for physicians, other medical personnel, and facility staff.
Protect the security of medical records to ensure confidentiality.
Responsible for “thinning” of overflow from in-house records and filing in discharge record order.
Audit transfer/discharge information to ensure accuracy and completeness.
Release information to persons or agencies according to regulations.
Assist with processing computer forms, nursing staff, and administrative staff as assigned.
Ensure certifications and/or recertifications for Medicare residents are signed by attending physicians.
Purge files yearly and send them to off-site location.
Track physician visits and inform the DON/ADON weekly of residents who need to be seen for visits.
Mail doctor orders and telephone orders for the campus.
Complete chart audits assigned by DON/ADON.
Maintain supplies and paperwork for all units.
Obtain monthly physician orders signatures.
Collect paperwork and time corrections from North and South units and deliver to designated staff members daily.
Comply with federal, state, and company policies, procedures, and regulations.
Operate computers programmed with software needed to record, store, and analyze resident information; operate copy/fax/printer machines to send documents and produce documents.
Must be able to work any shift as directed by the Administrator.