Medical Records Director – Bland

JOB DESCRIPTION

 

Position / Title:           Medical Records Supervisor   

Department:                 Medical Records

Reports To:                  Chief Administrative Officer

FLSA Status:                Salary, Exempt

 

SUMMARY:

The Medical Records Supervisor 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.

 

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.
  • Process discharges.
    • Update Admission/Discharge Register
    • Remove name plate from resident’s door.
    • Review medical chart to ensure a discharge note has been entered.
    • Review medical chart to verify receipt of physician order for discharge.
    • Send unsigned physician order for discharge to physician for signature.   Document and follow-up to ensure receipt of signed order. File signed order in medical chart.
    • Verify receipt of Discharge Sheet for each discipline recapping stay.
    • Consolidate overflow records with medical chart and move medical chart to Discharge Records Storage.

 

Maintain Daily Census and Admission/Discharge Register.

  • Record admissions, discharges, transfers and deaths appropriately on a daily basis.
  • Check census information against existing records for accuracy and completeness on a daily basis.
  • Verify census information against existing records; research discrepancies, and make necessary corrections on a daily basis.

 

Generate monthly reports and perform monthly audit of medical charts.

  • Generate Resident PPD, Influenza, and Pneumonia Vaccination List on the first day of each month. Identity residents who need annual PPD, Influenza and Pneumonia Vaccinations. Enter resident names and due dates on the MAR and follow-up with nursing staff to ensure vaccinations are received and update medical charts accordingly.
  • Conducts monthly medical record audits for compliance with policies and procedures.
  • Maintain accurate Physician Visit Logbook and Tickler System.
  • Monitor skilled certifications and re-certifications needing signature and alert Physician upon visit.
  • Track Annual History & Physicals due and alert Physician upon visit.

 

Thin medical charts on a quarterly basis.

  • Pull Nursing Notes dated more than 3 months prior from the medical chart and file in overflow records
  • Pull Physician Orders dated more than 3 months prior from the medical chart and file in overflow records
  • Pull Progress Notes dated more than 3 months prior from the medical chart and file in overflow records
  • Pull Lab Reports dated more than 3 months prior from the medical chart and file in overflow records

 

Maintain confidentiality of medical records.

  • Confer and correspond with residents, pharmacies, doctors, attorneys and others on non-routine requests for medical information and disclose medical information in accordance with appropriate confidentiality regulations and statutes.
  • Process requests for medical records and provide routine information to authorized requestors.
  • Adhere to the confidentiality standards of the Privacy Act and HIPAA.

 

DEGREE OF SUPERVISION:

The Medical Records Supervisor reports to and receives general direction from the Chief Administrative Officer.

 

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
  • Minimum of 3 years experience as a Medical Records Clerk or
  • 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.

 

RECEIPT AND ACKNOWLEDGEMENT:

I acknowledge and understand the following:

  • Receipt of the job description does not imply nor create a promise of employment, nor an employment contract of any kind, and that my employment is “at-will”.
  • The job description provides a general summary of the position in which I am employed, that the contents of this job description are job requirements and, at this time, I know of no limitations which would prevent me from performing these functions with our without accommodation. I further understand that it is my responsibility to inform my supervisor at any time that I am unable to perform these functions.
  • Job duties, tasks, work hours, and work requirements may be changed at any time.
  • Acceptable job performance includes completion of the job responsibilities, as well as compliance with the policies, procedures, rules and regulations.
  • I have read and understand this job description.

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