Medical Records Director - Autumn Creek

Rockport Healthcare Services; Chico (CA); On-site; USD 70,000 - 90,000; Full time

Job summary

Rockport Healthcare Services seeks a Medical Records Director to lead the health record program for a long-term care center. The role emphasizes maintaining compliance with federal/state requirements, supervising staff, and coordinating physician documentation.

The position requires strong English communication, medical terminology knowledge, and prior health records experience, preferably in long-term care, with basic computer skills. Supervisory duties may be involved.

Qualifications

• High school diploma is required.
• 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 setting.
• Prior health record experience preferred, including Point Click Care.
• Supervisory experience preferred.
• Basic computer experience preferred.

Responsibilities

• Maintains Health Record System according to Federal, State and Community requirements.
• Participates in assigned meetings and inservices.
• Meets unit work goals through assignment of staff to resident care needs.
• Monitors staff performance through coaching and recognizes effective performance or takes corrective action after coaching as needed.
• Initiates Resident Health Record and maintains logs and indices as required.
• Coordinates physician documentation and prepares statistical reports as required.
• Maintains unit filing system and releases information within regulatory requirements.

Skills

English proficiency

Administrative skills

Knowledge of medical terminology

Basic computer skills

Education

High School diploma

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.