Position Summary
The Medical Records Director (Non-Nurse) maintains patients’ clinical records, including coding, auditing, and staff education on recordkeeping procedures in accordance with applicable laws, regulations, and Life Care standards. This role also serves as the facility’s designated Privacy Officer.
Reports to the Executive Director (ED).
Essential Functions
- Audit and complete ongoing review of 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 and CPT/HCPCS coding systems.
- Communicate effectively with physicians, nursing staff, and allied health personnel.
- Interview, hire, train, evaluate, counsel, and supervise medical records staff.
- Maintain confidentiality of proprietary and confidential information.
- Support compliance program implementation and promote a culture of integrity.
Requirements & Qualifications
Education and Experience
- Bachelor’s degree or equivalent combination of education and experience.
- RHIA or RHIT credential preferred, or a degree in a health-related field with extensive training and demonstrated competence in HIM.
- Training in post-acute care health information management.
Qualifications
- Knowledge of state and federal legal requirements related to documentation, confidentiality, and health information.
- Proficiency with complex computer software systems.
- Functional knowledge in the field of practice.
- Ability to make independent decisions when needed.
- Strong knowledge of medical records practices, procedures, laws, regulations, and guidelines in a post-acute care facility.
- Ability to implement and interpret department programs, goals, objectives, policies, and procedures.
- Proficiency in medical coding, auditing, clinical records, privacy officer responsibilities, supervisory responsibilities, patient rights, and safety/sanitation.
- Ability to communicate and function effectively on an interdisciplinary team.
- Must be able to perform physical duties including sitting, standing, bending, lifting, pushing, pulling, stooping, walking, reaching, and moving intermittently during working hours.
- Must be able to lift and carry up to 35 lbs.
Location
Florida, US
Employment Type
Full-time
Experience Level
Director
Remote work allowed
No
Posted
1 month ago