Medical Records Director

Medical Records Director – Topaz Fiscal Services LLC

As Medical Records Director, you are the administrative authority responsible for ensuring that medical records are maintained in accordance with Federal and State Guidelines and company policies. You process and maintain private patient information in the healthcare facility’s database and assess records for completeness and accuracy.

• Enter patient data such as demographics, history, diagnostic procedures, and treatments into computer systems.
• Maintain medical facility records, storage, and retrieval systems to collect, classify, and store information.
• Prepare medical records for insurance and legal requests as required.
• Contact physicians regarding incomplete charts.
• Assist nursing staff and physicians with death certificates.
• Respond to requests for records from federal, state, or county courts, hospitals, physicians, and insurance after receiving direction from the administrator.
• Scan all medical records within 24 hours as policy requires.
• Perform chart audits, including:
  • Admission audits
  • Weekly audits of physician visits and progress notes
  • Monthly audits of progress notes for all departments, monthly summaries, history and physical, etc., to ensure all forms are present and completed.
  • Discharge audit – charts must be complete within 72 hours, including the discharge summary.
• Conduct weekly audits to ensure all residents have a complete medical record.
• Attend in‑service education programs to meet facility educational requirements.
• Be familiar with standard precautions, exposure control plan, fire drill, and evaluation procedures and know how to use them.

• High School Graduate
• 3+ years’ experience handling medical records in a licensed medical facility
• Exceptional organizational skills
• Data entry 40-50 wpm
• Proficient in information‑management programs and MS Office
• Excellent interpersonal and organizational skills
• Strong attention to detail
• Outstanding communication and interpersonal abilities
• Proficient in computer programs, including Microsoft Office and Outlook
• Knowledge of medical terminology
• Must be computer literate
• Comply with Residents’ Rights and Facility Policies and Procedures

Entry level

Part‑time

Health Care Provider – Hospitals and Health Care