Medical Records Director directs medical record-keeping operations and healthcare information management to ensure secure, accurate, and reliable patient information management that complies with data and privacy regulations. Develops policies and procedures and conducts continuous improvement activities to ensure effective and compliant record management. Being a Medical Records Director implements digital technologies and tools to gain efficiencies, facilitate record retrieval, and ensure secure storage. Provides training for medical records staff and information resources to end-users. Additionally, Medical Records Director coordinates with clinical and technical professionals to maintain robust records management systems and manage data for analysis and reporting. Typically requires a bachelor's degree in healthcare administration, a related field, or equivalent. May require Registered Health Information Administrator (RHIA) certification. Typically reports to a director. The Medical Records Director typically manages through subordinate managers and professionals in larger groups of moderate complexity. Provides input to strategic decisions that affect the functional area of responsibility. May give input into developing the budget. To be a Medical Records Director typically requires 3+ years of managerial experience. Capable of resolving escalated issues arising from operations and requiring coordination with other departments. (Copyright 2024 Salary.com)
POSITION SUMMARY:
Medical Records Specialist is responsible for the entering and/or processing of documents, clinical information, and medical orders, as well as the maintenance patients' electronic records. The Medical Records Specialist also assumes duties of the Team Assistant as assigned.
MINIMUM QUALIFICATION STANDARDS:
I. Education:
High school diploma or equivalent
II. Experience:
Minimum of two years office experience, preferably in a home care environment
PERFORMANCE REQUIREMENTS:
I. Performance Standards:
* Audits and processes physician signed plans of care and interim orders ensuring that they are complete and accurate
* Receives, processes, and tracks documents such as admission forms, consent forms, Medicare Non-Coverage Notices, and Home Health Advance Beneficiary Notices
Receives, prepares, and submits both internal and external record requests
* Reminds clinicians and notifies clinical team managers of overdue or missing documentation. Contacts clinicians as needed to clarify orders and other documents
* Enters clinical data into the electronic record, including clinical notes and signed medical orders, as requested
* Corrects or assists with correcting documents according to organization's procedures
* Acts as a resource to staff and managers for questions related to interim orders, order processing, and other clinical record documents. Assists clinicians to complete orders, forms, and records in conformance with regulations
* Maintains electronic clinical records for accuracy and proper billing
* Refers non-routine questions and situations related to electronic medical records to supervisor, clinical team manager, or Accounts Receivable, in order to acquire a solid understanding of regulations and clinical record requirements
* Runs reports as assigned
* Any other duties as assigned by supervisor