Medical Records Director Non Nurse/HIM
About The Position
The Medical Records Director (Non-Nurse) maintains patients’ clinical records, including coding and auditing, and provides staff education on recordkeeping procedures in accordance with applicable laws, regulations, and Life Care standards. The role serves as the facility’s designated Privacy Officer and reports to the Executive Director (ED). The director oversees medical records practices and staff, ensures compliance with health information and privacy requirements, and supports effective communication among physicians, nursing staff, allied health personnel, and the interdisciplinary team. The role also requires regular attendance, dependable judgment, and the ability to assist with patient evacuation and perform the listed physical activities.
Requirements
- Bachelor’s degree or an equivalent combination of education and experience.
- Credentialed as a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or have a degree in a health-related field with extensive training and demonstrated competence in the HIM field.
- Training in post-acute care health information management.
- Knowledge of state and federal legal requirements relating to documentation, confidentiality, and legal issues pertaining to health information.
- Efficient use of complex computer software systems.
- Functional knowledge in the field of practice.
- Ability to make independent decisions when circumstances warrant.
- Knowledge of medical records practices and procedures, and laws, regulations, and guidelines governing medical records functions in a post-acute care facility.
- Proficiency in medical coding, auditing, clinical records, privacy-officer responsibilities, supervisory responsibilities, patient rights, and safety and sanitation.
- Ability to read, write, speak, and understand English.
- Ability to sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours.
- Ability to lift 35 pounds from floor to waist and waist to shoulder, carry 35 pounds, and push or pull 35 pounds.
- Ability to concentrate, use reasoning skills and good judgment, and communicate and function productively on an interdisciplinary team.
- Adherence to company policies, the Life Care Code of Conduct, and required compliance training.
Responsibilities
- Audit and conduct ongoing reviews of patients’ clinical records to ensure documentation and performance compliance.
- Maintain current, overflow, and discharged record filing systems.
- Serve as the facility’s Privacy Officer for HIPAA compliance.
- Understand and apply long-term care payment systems, including Medicare.
- Use ICD-10-CM coding and CPT/HCPCS coding systems.
- Communicate effectively with physicians, nursing staff, and allied health personnel.
- Interview, hire, train, evaluate, counsel, and supervise medical records staff.
- Provide staff education regarding recordkeeping procedures.
- Exhibit excellent customer service and a positive attitude toward patients.
- Assist in the evacuation of patients.
- Maintain dependable, regular attendance and function productively on an interdisciplinary team.
- Implement and interpret medical records department programs, goals, objectives, policies, and procedures.
- Maintain confidentiality and implement applicable company compliance policies and procedures.
- Promote a culture of integrity, support good-faith reporting, and ensure department staff participation in compliance training.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
