We are in search of a Medical Records Director for the GEM Transitional Care Center located in Pasadena.The ideal candidate will be dedicated, detail-oriented, and passionate about maintaining the integrity and security of medical records. We are seeking someone who is not only skilled in managing complex information systems but also committed to enhancing the quality of care through meticulous documentation and compliance with healthcare standards. This role offers an opportunity to make a significant impact on the lives of our residents by ensuring their health information is accurately managed and readily accessible to support their care needs. If you meet the qualifications and are eager to join a dynamic team focused on excellence in healthcare, we encourage you to apply.

REQUIREMENTS:

High school graduation or equivalent. Good physical and mental health Knowledge of Medical Terminology. Basic computer and typing/data entry skills. General office skills including filing, organizing, etc; Oral and written communication skills; Good customer services and telephone skills; Long term care or healthcare experience preferable as a Coordinator of Health Information in another facility. Training as a Medical Records Secretary or equivalent. Experience with ICD-CM coding preferred. Knowledge of regulations, accreditation standards and professional standards of practice for health information in long term care. Knowledge of the budget process. REPORTING: The position of Medical Records Director reports to the Administrator.

JOB DUTIES: Responsible for the initiation, maintenance and filing of resident records in the facility. Maintain current policy and procedures for the medical records department. Monitor department budget as directed. Participate in the facility Quality Assurance and Assessment Committee. Maintain a quantitative/qualitative audit/monitoring process. Conduct comprehensive audits of charts on the following: Admission Advance Directives Bowel and Bladder Training Care Plans Clinical Overview Skilled Documentation Rehabilitation Documentation Weekly Summary Licensed Documentation Physician Orders Hospice MDS Perform focused reviews of problem areas. Trends and/or patterns, QA concerns, Quality Indicators and survey issues. Maintain admission register and complete coding and indexing of admission diagnosis. Complete chart closure process on all discharged resident charts. Complete the Monthly General Update Log. Complete the annual LTC-OSHPOD report Complete the year end census report. Maintain security of medical records. Maintain system for record filing, retention and destruction. Process monthly recapitulation of physician orders. Other duties as assigned by the Administrator.