POSITION SUMMARY

The purpose of your job position is to maintain resident medical records and health information in accordance with current federal, state and local guidelines that govern the facility and as directed by the Administrator.

The Director of Medical Records will treat each resident with kindness, dignity and respect. They will work cooperatively with all departments and multidisciplinary teams. They will demonstrate patience, initiative and willingness to assist residents that may be difficult or in discomfort. They will be committed to always doing the right thing.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Retrieving resident’s records when requested

Managing accurate and timely requests of medical records

Organizing and directing the medical records department in accordance with facility policies

Assembling and reviewing resident’s medical records as needed.

Ensuring the filing of all medical reports, doctors and nurses notes, x-ray, lab, etc.

Enforcing procedures to ensure all resident medical records are properly filed, coded, and signed

Maintaining a record of authorized information released from charts/records

Keeping active and inactive medical records as warranted by company policy

Protecting each residents file and data with confidentially per HIPAA standards

Abiding with all facility policies and procedures including not disclosing user ID codes and passwords

Attending meetings and serving on committees as needed

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies these are the only duties you will be required to perform as directed by management. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

REQUIREMENTS

Education / Licensure

High school diploma or GED

Knowledge of medical terminology, coding, indexing and legal aspects of health information helpful

Qualifications / Experience

Minimum of 2 years management experience

Minimum of 2 years managing medical records and complying with HIPAA regulations

Ability to use computer data base for medical records

Excellent verbal and written skills

Knowledge of Point Click Care helpful

Working Conditions

May encounter frequent interruptions

May be involved with residents, family and government agencies

May be requested to work beyond scheduled working hours at times

Is subject to call back during emergency conditions (e.g., severe weather, evacuation, post‑disaster, etc.)

May be necessary to assist in the evacuation of residents during emergency situations

May be exposed to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses

Physical Requirements

Must be able to move intermittently throughout the day

Repetitive hand motion

Must be able to push, pull, move and or lift up to 25 lbs. to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 15 feet

Ability to read fine print on progress notes and/or medical labels

• Per California state mandate, the COVID 19 vaccine is required for this position.