Medical Records Director

Live Oak Rehabilitation Center; San Gabriel (CA); On-site; USD 55,000 - 75,000; Full time

Job summary

Live Oak Rehabilitation Center is seeking a Medical Records Director to lead our medical records operations, ensuring accurate charting, timely admissions/discharges, and compliant documentation across the facility. The role requires strong organizational skills and proficiency with PCC to manage health information effectively.

The incumbent will work with nursing and medical staff, maintain logs, prepare charts for new admissions, audit records, and support QA initiatives to uphold data

Qualifications

• Experience in medical records management and documentation.
• Strong attention to detail and accuracy in charting.
• Ability to collaborate with healthcare professionals.
• Knowledge of HIPAA/privacy requirements.
• Proficiency with medical terminology and office technology.

Responsibilities

• Maintain daily admission and discharge logs for residents.
• Prepare charts for admissions with order forms.
• Audit and assemble discharged residents' records.
• Process physicians' orders and inputs using the PCC system.
• Operate computer to store, retrieve, and manage health information.
• Participate in QA programs and committee meetings.
• Attend mandated meetings and perform duties as assigned.

Skills

Healthcare record management

Attention to detail

Organizational skills

Collaboration with healthcare pros

HIPAA knowledge

Tools

PCC (Point Click Care)

Job description

We are seeking a Medical Records Director to join our team! The Medical Records Clerk primarily compiles and maintains medical records of patients of health care delivery system to document patient condition and treatment.

Medical Records Director Requirements

• Must be familiar with PCC (Point Click Care System)
• Fully vaccinated against COVID-19 including Booster shots
• Strong Organizational and Office Technology Skills
• Knowledge of HIPPA and Client Confidentiality Laws
• Proficient in Medical Terminology
• Comfortable in Collaborating with Healthcare Professionals
• Detail Oriented

Primary Medical Records Director Responsibilities

• Complies with the facility’s attendance policy requiring regular, reliable, and punctual attendance
• Maintains daily admission and discharge log for each resident
• Prepares charts for admission with chart order form in front of chart
• Checks charts on new admissions daily until all below required paperwork has been completed
• Prepares all charts with tabs following chart order sequence
• Assists with paperwork on new admissions
• Prepares all forms in the chart with resident identification information
• Assembles and audits discharged residents’ records
• Prepares computer sheets on scheduled dates for physician recaps and inputs physicians’ orders via the Medical Records Accu-Care computer system
• Operates computer to process, store, and retrieve health information
• Completes recaps on timeline agreed upon by Director of Nursing
• Completes audit schedule each day, week, and month
• Audits charts
• Participates in the Quality Assurance Program and Utilization Committee Meetings and passes CQI
• Follows up on all consultant/QA recommendations
• Utilizes medical records procedure manual as needed
• Responsible for maintaining up-to-day inventory of facility forms
• Attend mandated meetings: daily standup, weekly PPS, and monthly triple-check
• Performs other duties or functions as assigned by the Administrator

Other Responsibilities

• Ability to pull multiple reports using PCC system
• Assists with paperwork on new admissions and discharges
• Utilizes medical records procedure manual as needed. Does daily audits as assign
• Prepares files, records and logs under the supervision of the Medical Records Designee
• Requires attention to detail, lots of uninterrupted time at a desk with computer, and reliability
• Employees must be able to maintain consistent attendance
• Other duties may be assigned

PAY SCALE:

Depending on a number of factors, including, but not limited to location, regularly scheduled work shift, knowledge, skills, experience, and expertise.

This company is an Equal Opportunity / Affiantive Action Employer

All qualified applicants will receive consideration for employment without regard to disability, race, color, veteran status, religion, sex, or national origin.

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