About This Role
This role involves overseeing the maintenance of medical records in compliance with Federal and State Guidelines, as well as established policies and procedures. The Medical Records Director is responsible for ensuring the completeness and accuracy of patient records and managing private patient information within the healthcare facility's database.
Responsibilities
- Enter data, such as demographic characteristics, history, diagnostic procedures, or treatment into the computer
- Enter patient or treatment data into computers
- Maintain medical facility records or storage and retrieval systems to collect, classify, store, or information
- Prepare medical records for insurance and legal requests as required
- Contact physicians regarding incomplete charts
- Assist nursing staff and physicians with death certificates
- Respond to requests for records from Federal, State, or County Courts, hospitals, physicians, and insurance after getting direction from the administrator
- Scan all medical records as policy states, within 24 hours of receiving documents
- Perform chart audits as follows:
- Admission audits
- Weekly audits of physician visits and progress notes
- Monthly audits of progress notes for all departments, monthly summaries, history and physical, etc., to ensure all forms are present and completed
- Discharge audit - charts must be complete within 72 hours, including the discharge summary
- Do weekly audits to ensure that all residents have a complete medical record
- Attend in-service education programs in order to meet facility educational requirements
- Be familiar with Standard Precautions, Exposure, Control Plan, Fire Drill and Evaluation Procedures and know how to use them
Requirements
- High school graduate
- 3+ years' experience in handling medical records in a licensed medical facility
- Exceptional organizational skills
- Data entry (40-50 wpm)
- Proficient in information management programs and MS Office
- Excellent interpersonal and organizational skills
- Strong attention to detail
- Outstanding communication and interpersonal abilities
- Proficient in computer programs, including Microsoft Office and Outlook
- Knowledge of medical terminology
- Must be computer literate
- Comply with the Residents Rights and Facility Policies and Procedures
About the Company
We provide compassionate and personal 24-hour skilled care and rehabilitation services in a comfortable and friendly environment. Our main concern is caring, and we maintain high medical integrity, build team spirit among staff, and provide friendly, beautiful surroundings for patients.