Medical Records Director

New Today

Our Directors love what they do, and our residents see thisdemonstrated daily. This position offers work/life balance, opportunities foradvancement, and the chance to form meaningful bonds with our residents andtheir families. We recognize people as our most valuable asset and thebenefits we offer reflect our commitment to having the very best. Benefits offered:
Health Insurance Dental, Vision & Disability coverages also available 401K Retirement Plan with Employer Contributions Company Paid Life Insurance Professional, Friendly & Social Team Members Wage scale determined by years ofexperience. Benefits & bonuses available for full-time employees workingover 30 hours per week. If this interestsyou, that interests us! We're looking forward to having you on the team!
General Purpose: This position maintains the medical records for the facility inaccordance with policies and procedures established for the medical recordkeeping, under the guidance of the Health Information Consultant.
Qualifications: • Abilityto establish procedures and to suggest changes for smoother operations. • Ableto understand the Medical Record Systems, including filing and electronicmedical records. • Understandand utilize medical terminology, ICD-10-CM coding principles, concurrent anddischarge analysis procedures, medical legal aspects, and possess managementskills for a nursing facility. • Possesspersonal attributes to include professionalism, neatness, accuracy. • Mustpresent a professional appearance. • Mustbe able to cooperate and work well with fellow employees. • Mustbe knowledgeable of computer systems, system applications, and other officeequipment. • Mustbe able to meet all local health regulations and pass pre/post-employmentphysical exams, if required. Thisrequirement also includes drug screening, criminal background investigation,and reference inquiry. Medical RecordTechnician • Certificationas Registered Health Information Technician (RHIT) or Registered HealthInformation Administrator (RHIA) preferred • Activemember of the American Health Information Management Association (AHIMA) • Evidenceof maintaining continuing education (CE) requirements of the American HealthInformation Management Association. Duties andResponsibilities: Assure that the resident is properly registered in the necessary indices of the facility (i.e. Resident Number Register and Master Patient Index). Code admission diagnoses according to the ICD-10 CM coding guidelines and principles and enter codes into appropriate system(s), as required. Assure the admission summary (face sheet) is complete. Upon discharge, check records quantitatively to assure completeness and accuracy within thirty (30) days of the discharge or in accordance with state regulations. Determine whether additional transfer data is needed and request from the transferring facility if needed. Follow-up to assure receipt. Check the record quantitatively on admission and periodically to assure completeness, accuracy and internal consistency. Report trends to the QA/QAPI committee. Communicate with and assist the medical staff and allied health personnel in updating records. Maintain the flow of the reports to the records. Update diagnostic lists as changes occur by coding additional diagnoses documented by physicians and resolving inactive diagnoses. Review diagnostic lists for accuracy in conjunction with the MDS schedule and sign for accuracy of MDS Section I, as required. Check the discharge documentation quantitatively to assure completeness, accuracy, and internal consistency. Obtain complete and accurate records within thirty (30) days of discharge or in accordance with state regulations. Assure face sheet discharge information is correct. Assure all required reports are in the record. Follow appropriate procedures for closing a record permanently incomplete, if required. Maintain the Resident Number Registry. Verify the accuracy of the Master Resident Index upon admission and discharge of the resident. Maintain overflow records. Maintain a tracking system for physician visits and the authentication of orders. Maintain accurate and timely Medicare certifications, as required. Collect, correlate and maintain statistical data as needed. Provide information, when requested, to those involved in research projects and studies with the approval of the center administrator. Assist the medical staff by providing data from the health records for Utilization Review, Triple Check, QAPI and various audits. Maintain the numerical filing system for records. Maintain the unit numbering system for record identification. Maintain the necessary sign-out and follow-up controls of records. Maintain and control release of information to authorized persons. Type and/or transcribe reports of correspondence according to the needs of the HIM department. Attend faculty meetings as required. Orientation of new staff members to the HIM department. Orientation and training of nursing and ancillary departments involved in the documentation process. This will involve both state and Federal regulations and center policies and procedures, as well as documentation recovery education. Ensure medical record copies are provided per policy and/or regulation to the appropriate resident and/or resident representative. Ensure medical record copy fees are charged and collected per policy. Ensure legal medical record requests are copied, prepared neatly, reviewed prior to delivery and sent/delivered in the specified time frame. Responsible for the evaluations, scheduling and disciplinary action of health information employees within the department. Determination of budgetary needs for both routine and capital expenditures, in conjunction with the administrator. All other duties as assigned. #INDRO123
Physical and SensoryRequirements: Walking, sitting,standing, reaching, stooping, bending, lifting, grasping, pushing and pulling,and fine-hand coordination. Ability to hear and respond to overhead pages.Ability to communicate with residents, families, personnel, vendors, andconsultants. Ability to apply training and in-service education provided. Mustpresent a neat, clean, professional appearance and demonstrate a positiveapproach with employees and residents.
Location:
Dade City, FL, United States
Job Type:
FullTime
Category:
Healthcare Practitioners And Technical Occupations

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