Job Posting for Medical Records Director at Crystal Ridge Care Center
POSITION SUMMARY:
The Medical Records Director assumes authority,
responsibility and accountability for the record keeping procedures and storage
of all clinical records in a manner consistent with facility policies and
procedures, professional standards and county, state and federal laws and
regulations, as applicable, for long term care facilities. Establishes and implements policies to ensure
that records are complete, accurately documented, readily accessible and
systematically organized.
QUALIFICATIONS/REQUIREMENTS:
Education: High School graduate or equivalent
Work Experience:
At least on year of clerical
experience, including filing Experience as a medical records practitioner in long term care facility
preferred Ability to type, calculate and perform data entry skills
ESSENTIAL JOB FUNCTIONS:
•
Perform health record maintenance duties;
assembling, labeling, cleaning, filing and purging documents •
Keys information into computer systems,
including EMR •
Maintain stock of forms and record supplies •
Request necessary resident information from
transferring facilities •
Process external information requests from
authorized institutions and individuals • Compile
statistical data at the direction of Administrator • Prepare
Alirts (OSHPD) yearly report • Maintain
the confidentiality and physical security of health records in accordance with
HIPPA rules and regulationS • Perform
concurrent and discharge quantitative audits of health records. Physician visit audits. Notification of physician when required by
procedure • Develop
and perform specialized audits on a predetermined time sequenced rotation with
plan of completion to be defined and time limited. Audit all current resident charts to notate
deficiencies and obtain and assist in corrections on a scheduled basis. Submit deficiency reports and to persons
responsible for correction with date of completion to be returned (3 days) to
the Administrator, Director of Nurses or designated representatives. • Disease
index coding at time of admission, when diagnostic status alters and within 30
days of discharge date. Complete any
outstanding disease index coding • Discharge
charts must include the following information prior to filing: a.
Final Diagnosis and/or Death Certificate b. Completed
Disease Index Coding c.
Obtain all outstanding documentation and
required signatures to meet criteria mandated by facility policy. • Mail
telephone order forms to physicians daily, assure prompt return and file in
chart • Prepare
Physician Orders, Medication/Treatment records, ADL records and Resident Care
Plans for accurate input into computer and printing on scheduled basis • Perform
computer operation functions including regular input of data and printing on a
scheduled basis • Keep
computer terminal(s), keyboard(s) and office clean and functional • Maintain
appropriate medical record storage and destruction of medical records
consistent with facility policy • Follow-up
on reports and recommendations submitted by the Medical Records Consultants and
Service Center Medical Records Analysts • Report
to the Director of Nursing and Administrator significant documentation problems
• Attend
and participate in in-service education and staff meetings as required,
including risk management and daily stand-up meetings. Maintain minutes of meetings/files as
requested • Be
courteous, considerate and cooperative when communication with all facility
personnel, resident and public • React
appropriately to emergencies and disaster situations
JOB
FUNCTIONS:
• Demonstrate
knowledge of, and respect for, the rights, dignity and individuality of each
resident in all interactions • Appreciates
the importance of maintaining confidentiality of resident and facility
information • Demonstrate
honesty and integrity at all times in the care and use of resident and facility
property • Must
be able to key information into computer systems • Able
to understand and to follow written and/or verbal directions. Able to express self adequately in oral
and/or written communication. Able to
communicate effectively with staff members, other professional staff,
consultants and residents • Demonstrates
ability to prioritize
tasks/responsibilities and complete duties/projects within allotted time • Able
to respond to change productively and to handle additional tasks/projects as
assigned • Able
to carryout the essential functions of this job (with or without reasonable
accommodation) without posing specific, current risk of substantial harm to health
and safety of self and others • Other
duties as assigned by the Administrator
Salary.com Estimation for Medical Records Director in Grass Valley, CA
$82,177 to $109,164
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