Medical Records Director Non Nurse/HIM

Employment Type

: Full-Time

Industry

: Healthcare - Allied Health



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Position Summary

  • The Medical Records Director (Non-Nurse) maintains the patients’ clinical records, including coding, auditing, and providing pertinent staff education regarding recordkeeping procedures in accordance with all applicable laws, regulations, and Life Care standards. Serves as the designated Privacy Officer for the facility.
  • Reports to Executive Director (ED)
  • Education, Experience, and Licensure/Certifications

  • Must possess a bachelor’s degree OR an equivalent combination of education and experience
  • Must be credentialed as a Registered Health Information Administrator (RHIA) OR as a Registered Health Information Technician (RHIT) OR have a degree in a health related field with extensive training and demonstrated competence in the HIM field
  • Must have training in post-acute care health information management
  • Specific Requirements

  • Must demonstrate knowledge of State and Federal legal requirements relating to documentation, confidentiality, and legal issues pertaining to health information
  • Must demonstrate efficient usage of complex computer software systems
  • Must have functional knowledge in field of practice
  • Must possess the ability to make independent decisions when circumstances warrant such action
  • Must be knowledgeable of medical records practices and procedures as well as the laws, regulations, and guidelines governing medical records functions in the post-acute care facility
  • Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the medical records department
  • Must perform proficiently in all competency areas including but not limited to: medical coding, auditing, clinical records, privacy official responsibilities, supervisory responsibilities, patient rights, and safety and sanitation
  • Maintains confidentiality of all proprietary and/or confidential information
  • Must understand and follow company policies including harassment and compliance procedures
  • Displays integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training
  • Promotes a culture of integrity, maintains an “open door” policy, and does not participate in or allow retaliation against those who report good faith concerns
  • Actively implements the compliance program and Code of Conduct and ensures 100% participation by department staff
  • Essential Functions

  • Must be able to audit and complete ongoing review of all patients’ clinical records to ensure documentation and performance compliance
  • Must be able to maintain current, overflow, and discharged record filing systems
  • Must serve as the facility’s Privacy Officer for HIPAA compliance
  • Must understand and apply LTC payment systems, including Medicare
  • Must be able to use ICD-10-CM coding
  • Must be able to use CPT/HCPCS coding systems
  • Must be able to effectively communicate with physicians, nursing staff, and allied health personnel
  • Must be able to interview, hire, train, evaluate, counsel, and supervise medical records staff
  • Must exhibit excellent customer service and a positive attitude towards patients
  • Must be able to assist in the evacuation of patients
  • Must demonstrate dependable, regular attendance
  • Must be able to concentrate and use reasoning skills and good judgment
  • Must be able to communicate and function productively in an interdisciplinary team
  • Must be able to sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
  • Must be able to read, write, speak, and understand the English language
  • Must be able to lift 35 lbs floor to waist, lift 35 lbs waist to shoulder, lift and carry 35 lbs, and push/pull 35 lbs

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