Medical Records Director

Description Directs, establishes and plans the overall policies and goals for the medical record department in support of facility strategic objectives and program planning. Ensures that health information management practices meet JCAHO accreditation standards, Medical Staff Bylaws, state and federal guidelines and privacy practices.

Education: College, certification (RHIA or RHIT) attained.

Training and Experience:  Two years experience working in management and coding.   Must have good work organization, prioritization and time management skills, and sound judgment and decision making skills. Familiarity with general medical terminology needed for specific familiarity with psychiatric terminology. Clerical and office procedure skills, business correspondence and communication skills as well as skills in use of office equipment.

Requirements 1. Supports facility internal and external customer service standards: responds to direct requests or questions in a timely manner; maintains composure during stressful interactions; demonstrates willingness to accept changes in job responsibilities; offers and accepts constructive feedback in peer and supervisory relationships; modifies behavior in response to feedback; collaborates with employees in department to continually improve service delivery or facility operations; supports facility public relations and community education efforts.

2. Medical Records Processing
a. Assembles and analyzes discharged patient records within 48 hours of discharge with a minimum 95 percent accuracy rate. Ensures all entries are signed and dictation is on medical records.
b. Analyzes records to ensure compliance with government, accrediting, regulatory and organization requirements.
c. Communicates record of deficiencies to appropriate staff.
d. Facilitates completion of deficiencies via verbal notification to staff and weekly delinquency letters.
e. Follows up on completion of deficiencies with staff and initiates suspensions for delinquencies when appropriate.
f. Ensures all discharged records are retrieved from units on a daily basis.

3. Reimbursement
a. Assigns ICD-9-CM codes to patient records based on a thorough review of the medical record and established coding guidelines by AHIMA, AHA, AMA and regulatory agencies. Maintains a minimum 95 percent accuracy rate.
b. Ensures that records are coded within 4 days of discharge.
c. Seeks assistance when needed regarding coding questions.

4. Quality Improvement
a. Actively participates in facility-wide continuous Performance Improvement Plan.
b. Notifies CEO of any problems with transcription company’s performance.

5. Release of Information
a. Responds appropriately to all subpoenas and court orders in accordance with State and Federal laws.
b. Adheres to facility release of information guidelines at all times.
c. Is polite and helpful to individuals requesting release of information.
d. Processes all requests for ROI in accordance with applicable state and federal statutes.

6. Filing
a. Files transcribed reports for patients upon receipt from the transcription company. Files transcribed reports for discharged patients within two days of receipt.
b. Provides physicians with copies of dictated reports when appropriate.
c. Files “loose” reports received from other departments on a daily basis.
d. Retrieves medical records for authorized staff when requested.
e. Maintains neat and orderly files which include moving sections of the files to allow room for additional filing.
f. Appropriately sorts and distributes HIS mail on a daily basis.