Medical Records Director Non Nurse/HIM

Position Summary:The Medical Records Director (Non-Nurse) maintains the patients’ clinical records, including coding, auditing, and providing pertinent staff education regarding recordkeeping procedures in accordance with all applicable laws, regulations, and Life Care standards. Serves as the designated Privacy Officer for the facility.

Reports to Executive Director (ED)

Education, Experience, and Licensure/Certifications:Must possess a bachelor’s degree OR an equivalent combination of education and experience

Must be 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

Must have training in post-acute care health information management

Specific Requirements:Must demonstrate knowledge of State and Federal legal requirements relating to documentation, confidentiality, and legal issues pertaining to health information

Must demonstrate efficient usage of complex computer software systems

Must have functional knowledge in field of practice

Must possess the ability to make independent decisions when circumstances warrant such action

Must be knowledgeable of medical records practices and procedures as well as the laws, regulations, and guidelines governing medical records functions in the post-acute care facility

Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the medical records department

Must perform proficiently in all competency areas including but not limited to: medical coding, auditing, clinical records, privacy official responsibilities, supervisory responsibilities, patient rights, and safety and sanitation

Maintains confidentiality of all proprietary and/or confidential information

Must 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

Promotes a culture of integrity, maintains an “open door” policy, and does not participate in or allow retaliation against those who report good faith concerns

Actively implements the compliance program and Code of Conduct and ensures 100% participation by department staff

Essential Functions:Must be able to audit and complete ongoing review of all patients’ clinical records to ensure documentation and performance compliance

Must be able to maintain current, overflow, and discharged record filing systems

Must serve as the facility’s Privacy Officer for HIPAA compliance

Must understand and apply LTC payment systems, including Medicare

Must be able to use ICD-10-CM coding

Must be able to use CPT/HCPCS coding systems

Must be able to effectively communicate with physicians, nursing staff, and allied health personnel

Must be able to interview, hire, train, evaluate, counsel, and supervise medical records staff

Must exhibit excellent customer service and a positive attitude towards patients

Must be able to assist in the evacuation of patients

Must demonstrate dependable, regular attendance

Must be able to concentrate and use reasoning skills and good judgment

Must be able to communicate and function productively in an interdisciplinary team

Must be able to sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours

Must be able to read, write, speak, and understand the English language

Must be able to lift 35 lbs floor to waist, lift 35 lbs waist to shoulder, lift and carry 35 lbs, and push/pull 35 lbs