Medical Records Director

POSITION SUMMARY

The Medical Records Coordinator is responsible for the maintenance of resident health records and history in compliance with state and federal requirements (including HIPAA) and in partnership with the clinical leadership team.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Prepares clinical record for admission by collecting information from nursing staff, physicians, and other sources and updates records pertaining to quality resident care in accordance with state and federal regulations and guidance.

2. Completes state-specific daily and monthly Medical Records task lists.

3. Ensures monthly physician recaps are reviewed in accordance with Pine Ridge policy and procedure.

4. Prepares monthly flow sheets and submits to Nursing Department for review.

5. Monitors and audits records for completeness and accuracy in accordance with Pine Ridge policy and state/federal regulations.

6. Prepares and submits audit reports in the appropriate format to the Administrator, Director of Nursing Services, and other department leaders as necessary.

7. Processes and files incoming and outgoing mail from physicians, hospitals, agencies, and other health care entities.

8. Receives and coordinates the response to requests for clinical records from third party entities in partnership with corporate legal and clinical teams.

9. Processes and maintains discharge and transfer records according to Pine Ridge policy and state/federal regulation.

10. Identifies, creates, records, and maintains an index of resident diagnostic codes and diagnostic sheets.

11. Participates in clinical review meetings as required per Pine Ridge policy and procedure.

12. Participates and attends training sessions, in-service meetings, and other staff meetings as requested.

13. Maintains an organized and secure workspace for the efficient processing and retention of resident records.

14. Maintains in-depth knowledge of medical records and stays apprised with industry changes regarding medical coding and documentation best practices.

15. Performs other duties as assigned

QUALIFICATIONS AND EXPERIENCE

Minimum of 1 year experience working in medical records, preferably in skilled nursing or similar experience. Strong attention to detail. Knowledge of medical coding and Electronic Health Records (EHR). EDUCATION Associate’s degree or equivalent knowledge and skills obtained through a combination of education, training, and experience.

SUPERVISORY RESPONSIBILITIES

This position generally does not have supervisory responsibilities. In some locations, the Medical Records Coordinator may supervise a Medical Records Assistant.

LANGUAGE SKILLS

Ability to communicate effectively, in English, both verbally and in writing, with personnel at all levels of the organization, residents and their families, and members of the community. Ability to read and interpret documents, including safety rules, operating and maintenance instructions, and procedure manuals.

MATHEMATICAL SKILLS

Ability to maintain, understand, and review all reports and records.

REASONING ABILITY

Ability to accurately assess, troubleshoot, and problem-solve needs and evaluate results

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.