Medical Records Director (Registered Nurse/RN)

Position Summary

The RN Medical Records Director maintains the patients' clinical records, including coding, auditing, and providing pertinent staff education regarding recordkeeping procedures. Serves as the designated Privacy Officer for the facility in accordance with all applicable laws, regulations, and Life Care standards.

Education, Experience, and Licensure Requirements

• Bachelor's degree OR an equivalent combination of education and experience
• Credentialed as a Registered Health Information Administrator (RHIA) OR as a Registered Health Information Technician (RHIT) OR have a degree in a health related field with extensive training and demonstrated competence in the HIM field
• Training in post acute care health information management
• Currently licensed/registered in applicable State. Must maintain an active Registered Nurse (RN) license in good standing throughout employment.

Specific Job Requirements

• Demonstrate efficient usage of complex computer software systems
• Functional knowledge in field of practice
• Make independent decisions when circumstances warrant such action
• Knowledgeable of practices and procedures as well as the laws, regulations, and guidelines governing functions in the post acute care facility
• Implement and interpret the programs, goals, objectives, policies, and procedures of the department
• Perform proficiently in all competency areas including but not limited to: patient rights, and safety and sanitation
• Maintains professional working relationships with all associates, vendors, etc.
• Maintains confidentiality of all proprietary and/or confidential information
• Understand and follow company policies including harassment and compliance procedures
• Displays integrity and professionalism by adhering to Life Care's Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training

Essential Functions

• Contact physician for order clarifications and transcribe and communicate to nursing staff when indicated
• Participate in monthly medication and MAR reconciliation
• Audit and complete ongoing review of all patients' clinical records to ensure documentation and performance compliance
• Maintain current, overflow, and discharged record filing systems
• Serve as the facility's Privacy Officer for HIPAA compliance
• Understand and apply LTC payment systems, including Medicare
• Use ICD 10 CM coding
• Use CPT/HCPCS coding systems
• Effectively communicate with physicians, nursing staff, and allied health personnel
• Interview, hire, train, evaluate, counsel, and supervise medical records staff
• Exhibit excellent customer service and a positive attitude towards patients
• Assist in the evacuation of patients
• Demonstrate dependable, regular attendance
• Concentrate and use reasoning skills and good judgment
• Communicate and function productively on an interdisciplinary team
• Sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
• Read, write, speak, and understand the English language

An Equal Opportunity Employer