Medical Records

Big Sky HospiceBozeman, MT

About The Position

Responsible for managing all aspects of maintaining and protecting organization clinical records including the management of the clinical records team.

Requirements

  • At least three years of experience in clinical records management preferably in home health or hospice care operations.
  • Information systems knowledge required.
  • Demonstrated ability to supervise and direct clerical personnel.
  • Knowledge of corporate business management and governmental regulations
  • Demonstrates good communication skills and public relations skills.
  • Demonstrates autonomy, organization, assertiveness, flexibility and cooperation in performing job responsibilities.

Responsibilities

  • Manages all daily clinical records functions including establishing and implementing clinical records policies.
  • Ensures clinical record systems are maintained in compliance with state, federal and regulations.
  • Maintains comprehensive working knowledge of state, federal regulations and serves as a resource for appropriate organization personnel.
  • Protects all clinical records through the establishment and implementation of control procedures for all open and closed records.
  • Protects the confidentiality of patient and organization information through effective controls and direct supervision of clinical records.
  • Forwards copies of clinical records to authorized users according to policy.
  • Completes an administrative record audit following patient discharge and forwards abnormal results to the Clinical Director or their designee for clinical audit.
  • Monitors aged unsigned physician orders and submit second and third requests for signed orders to overdue physicians, calls or visit the offices of seriously overdue physicians.
  • Supervises the use of the clinical records information system and maintains a comprehensive working knowledge of the system including upgrades and enhancements.
  • Manages the members of the clinical record team to ensure accurate and prompt filing and retrieval of clinical records.
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