Medical Records Director

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 Prestige 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 Prestige 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 Prestige 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 Prestige 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.

COMPANY WIDE RESPONSIBILITIES

1. Demonstrates Core Values of Respect, Integrity, Commitment, and Trust.

2. Supports a dignified and caring atmosphere with residents, residents’ families, visitors, and staff.

3. Protects privacy and confidentiality of information pertaining to residents, team members, the department/center/community, and company information and records.

4. Maintains a safe and secure working environment and practices safe working habits.

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.

WORK ENVIRONMENT

Primarily works in an office setting within a skilled nursing center. Daily in-person attendance is an essential function of this position

Summary of Benefits:

Join us at Pine Ridge Post Acute, where your dedication and skills will be valued every day!