Medical Records Director

Bland County Nursing & Rehab Center•Bastian, VA

1d•Onsite

About The Position

The Medical Records Director reports to and receives general direction from the Chief Administrative Officer and is responsible for the facility’s medical records program. This role serves as an administrative specialist in the medical records field and as one of the facility’s HIPAA specialists, providing guidance to residents and professional staff on their rights regarding medical information. The Director maintains and releases medical information in accordance with the Privacy Act.

Requirements

Must possess, as a minimum, a high school diploma or equivalent.
Must possess a current certification as a Registered Health Information Technician (RHIT) issued by the American Health Information Management Association or 1-5 years of experience as a Medical Records Clerk or Medical Records Supervisor preferred.
Medical terminology
Knowledge of medications
ICD-9 Coding
Principles and practices of medical records management.
Health Insurance Portability and Accountability Act (HIPAA)
Federal and state laws governing medical records administration.

Nice To Haves

1-5 years of experience as a Medical Records Clerk or Medical Records Supervisor

Responsibilities

Prepare, review, and maintain hard copy and electronic medical charts in accordance with established laws, rules, and regulations.
Process new admissions.
Prepare medical chart and enter data in computer system.
Photograph the resident.
Prepare Face Sheet.
Update Admission/Discharge Register.
Prepare and place name plate on resident’s door.
Review chart to verify that all assessments have been completed and all labs have been ordered.
Daily maintenance of medical charts.
Transcribe physician orders, treatments and medications on a daily basis.
Check the physician orders for accuracy and diagnosis.
Send unsigned physician orders to physician for signature.
Document and follow-up to ensure receipt of signed order.
File signed physician orders in the medical chart.
Process face sheet changes, payer source changes, and room changes.
Provide appropriate ICD-9 coding to clinical reports and documents as appropriate.
Sort, file and collate medical records information such as admission slips, lab reports and clinical notes into resident medical charts in appropriate sequence and in accordance with established procedures.
Examine resident medical charts for completeness ensuring all required information is included; note any deficiencies and refer to appropriate area for follow-up.
Research lost or missing records.
Prints progress notes and other portion of the electronic record based on established policy and procedures.