Medical Records Director in Bastian, Virginia at Bland County Nursing & Rehab Center

SUMMARY:

The Medical Records Director reports to and receives general direction from the Chief Administrative Officer and is responsible for the facility’s medical records program; serves as an administrative specialist in the medical records field; serves as one of the facility’s HIPAA specialists providing guidance to residents and professional staff on their rights regarding medical information; maintains and releases medical information in accordance with the Privacy Act.

Schedule: Full-Time, Weekdays, 8 Hour Shifts

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Prepare, review, and maintain hard copy and electronic medical charts in accordance with

established laws, rules, and regulations.

• Process new admissions.
• Prepare medical chart and enter data in computer system.
• Photograph the resident.
• Prepare Face Sheet.
• Update Admission/Discharge Register
• Prepare and place name plate on resident’s door.
• Review chart to verify that all assessments have been completed and all labs have been ordered.
• Daily maintenance of medical charts.
• Transcribe physician orders, treatments and medications on a daily basis.
• Check the physician orders for accuracy and diagnosis.
• Send unsigned physician orders to physician for signature. Document and follow-up to ensure receipt of signed order.
• File signed physician orders in the medical chart.
• Process face sheet changes, payer source changes, and room changes.
• Provide appropriate ICD-9 coding to clinical reports and documents as appropriate.
• Sort, file and collate medical records information such as admission slips, lab reports and clinical notes into resident medical charts in appropriate sequence and in accordance with established procedures.
• Examine resident medical charts for completeness ensuring all required information is included; note any deficiencies and refer to appropriate area for follow-up.
• Research lost or missing records.
• Prints progress notes and other portion of the electronic record based on established policy and procedures

QUALIFICATIONS:

• Must possess, as a minimum, a high school diploma or equivalent.
• Must possess a current certification as a Registered Health Information Technician (RHIT) issued by the American Health Information Management Association or
• 1-5 years of experience as a Medical Records Clerk or Medical Records Supervisor preferred.
• Combination of education, training and experience which provides the following knowledge and skills:
• Medical terminology
• Knowledge of medications
• ICD-9 Coding
• Principles and practices of medical records management.
• Health Insurance Portability and Accountability Act (HIPAA)
• Federal and state laws governing medical records administration.

PHYSICAL AND MENTAL DEMANDS:

• Must be able to lift and/or move up to 25 pounds.
• Must be able to work outside of normal work hours including nights, holidays, and weekends as needed to meet facility and position demands.
• Must be free of diseases that may be transmitted in the performance of job responsibilities during the stage of communicability.
• Must be able to relate to and work with ill, disabled, elderly, emotionally upset and at times hostile people within the facility.

WORKING ENVIRONMENT:

Work is usually performed in a typical office setting. Works beyond normal duty hours, on weekends and holidays when necessary. Interacts with residents, family members, and staff under all conditions and circumstances. Is subject to hostile and emotionally upset residents, family members, and visitors. Exposure to infectious waste, diseases, and conditions including

but not limited to exposure to hepatitis B viruses