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 regarding recordkeeping procedures in accordance with applicable laws, regulations, and Life Care standards. The position serves as the facility’s designated Privacy Officer and reports to the Executive Director (ED). The director oversees medical records systems and staff, supports HIPAA compliance, and ensures clinical records meet documentation and performance requirements. The role requires knowledge of post-acute care health information management, medical records laws and procedures, coding systems, and long-term care payment systems, including Medicare.
Requirements
- Bachelor’s degree or an equivalent combination of education and experience.
- Credentialed as a Registered Health Information Administrator (RHIA), a Registered Health Information Technician (RHIT), or hold 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 the laws, regulations, and guidelines governing medical records functions in a post-acute care facility.
- Proficiency in medical coding, auditing, clinical records, privacy official responsibilities, supervisory responsibilities, patient rights, and safety and sanitation.
- Ability to lift 35 pounds from floor to waist, lift 35 pounds from waist to shoulder, lift and carry 35 pounds, and push or pull 35 pounds.
- Ability to read, write, speak, and understand English.
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.
- Use 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 pertinent staff education regarding recordkeeping procedures.
- Exhibit excellent customer service and a positive attitude toward patients.
- Assist in the evacuation of patients.
- Demonstrate dependable, regular attendance; concentrate and use reasoning skills and good judgment; and communicate and function productively on an interdisciplinary team.
- Implement and interpret the medical records department’s programs, goals, objectives, policies, and procedures.
- Maintain confidentiality of proprietary and confidential information and follow company policies and compliance procedures.
- Promote a culture of integrity, maintain an open-door policy, and not participate in or allow retaliation against people reporting good-faith concerns.
- Actively implement the compliance program and Code of Conduct and ensure full participation by department staff.
- Read, write, speak, and understand English.
- Sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours; lift and carry up to 35 pounds and push or pull up to 35 pounds.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
