Medical Records Director

Medical Records Director

Status:
Full-time

Schedule:

Monday - Friday

Wage: $30 - $36/hour

Location:

Avamere Rehab of Burien - 1031 SW 130th St, Burien, WA

Job Summary

A Medical Records Director in a long-term care facility is responsible for overseeing the complete lifecycle of resident records, ensuring their accuracy, completeness, and compliance with regulations and standards. This includes managing electronic health record systems, handling requests for information, and ensuring proper storage and retrieval of records.

Essential Duties and Job Responsibilities

• Oversee adherence to facility, state, and federal regulations regarding medical record keeping and resident privacy.
• Develop, implement, and maintain systems for organizing, indexing, and retrieving medical records, both electronic and paper.
• Oversee the use and maintenance of the facility's electronic medical records system (Point Click Care), ensuring data integrity and security.
• Manage the release of resident information to authorized individuals, agencies, or insurance companies in accordance with legal and regulatory requirements.
• Ensure the accuracy, completeness, and timely completion of medical records.
• Compile and report relevant statistical information from medical records, such as resident demographics, diagnoses, and procedures.
• Ensure efficient and timely retrieval of medical records for various purposes, including staff requests, legal requests, and audits.
• Supervise the assignment of appropriate codes for diagnoses, procedures, and other medical information.
• Maintain accurate records of all actions taken, including record releases, audits, and system updates.
• Identify areas for improvement in medical record systems and implement changes to enhance efficiency and accuracy.
• Effectively communicate necessary resident information to charge nurses, director of nursing, and/or administrator.
• Must be knowledgeable on federal and state laws regarding medical records.
• Review and audit admissions, discharges, change of condition, and other pertinent records on nursing units.
• Ensure that incomplete records/charts are returned to nursing service for correction.
• Abstract information from records as authorized/requested for insurance companies and other third-party payers.
• Ensure that registries are properly maintained for admission and discharge of residents.
• Develop and maintain a good working rapport with inter-department personnel, as well as other departments within the facility to assure that medical records can be properly maintained and problem areas can be identified and corrected.