Medical Records Director

Autumn Creek Post Acute; Chico (CA); On-site; USD 65,000 - 90,000; Full time

Job summary

Autumn Creek Post Acute is seeking a Medical Records Director to oversee health records services at the center. You will develop and maintain the health record system in compliance with federal, state, and center policies, while coordinating with clinical teams to ensure accurate documentation.

The ideal candidate has a high school diploma, strong English skills, and prior long-term care health record experience, including familiarity with PointClickCare.

Qualifications

• High School diploma.
• English language skills required for business.

Responsibilities

• Maintains Health Record System according to Federal, State and Community requirements.
• Participates in assigned meetings and inservices.
• Meets unit work goals through staff assignment.
• Monitors staff performance through coaching and recognition.
• Initiates Resident Health Record and maintains logs and indices as required.
• Coordinates documentation with physicians and handles releases of information per regulations.
• Presents professional image to consumers and ensures patient/resident rights are protected.

Skills

English proficiency

Administrative skills

Organizational skills

Medical terminology

Long-term care experience

Supervisory experience

Basic computer skills

Education

High School diploma

Tools

PointClickCare

Job description

Medical Records Director assists in developing and maintaining an appropriate health record service and system for the center.

Medical Records Director QUALIFICATIONS

• High School diploma.
• Strong written and verbal skills in English necessary for business.
• Administrative and organizational ability.
• Knowledge of medical terminology.
• Previous experience in a long term care care setting.
• Prior health record experience preferred. Including Point Click Care
• Supervisory experience preferred.
• Basic computer experience preferred.

Medical Records Director GENERAL DUTIES AND RESPONSIBILITIES

ADMINISTRATIVE

• Maintains Health Record System according to Federal, State and Community requirements.
• Participates in assigned meetings and inservices.

Medical Records Director SUPERVISION (if applicable)

• Meets unit work goals through assignment of staff to resident care needs.
• Monitors staff performance through coaching, praises and recognizes effective performance or takes direct corrective action after coaching (counseling) as needed.

Medical Records Director TECHNICAL

• Initiates Resident Health Record.
• Initiates and maintains logs and indices as required:
• Admission/Discharge Register
• Master Patient Index
• Disease Index
• Medicare Log (if applicable)
• Job Descriptions Manual
• Health Record Coordinator (Note: also may be referred to as Health Records Director or Medical Records Director in Health Records Manual.)
• Administrator
• Audit System
• Discharge Control Log
• Chart Removal Log
• Resident Care Plan Log
• Telephone Audit Log
• Performs Audits
• Admissions
• Discharge
• Routine Quality Assurance Audits
• Special as required
• Coordinates Physician Documentation
• Telephone Orders
• History and Physicals
• Monthly Physicians Orders
• Physicians’ Progress Notes
• Certifications and Recertifications
• Discharge Summaries
• Thins charts and maintains overflow files as required.
• Maintains and controls release of information within State, Federal and HIPPA regulations:
• Subpoena in conjunction with Senior Vice President of Clinical Compliance
• Correspondence – including legal
• Access to Records
• Records and maintains minutes of meetings as assigned.
• Inputs and prints computerized medical records forms.
• Prepares statistical reports as required.
• Destroys old health records as required.
• Assembles, analyzes and completes discharge records.
• Maintains unit filing system.

Medical Records Director CONSUMER SERVICE

• Presents professional image to consumers through dress, behavior and speech.
• Adheres to Company standards for resolving consumer concerns.
• Ensures that all consumer/resident rights are protected.