Medical Records Director Non Nurse/HIM

About the role

The Medical Records Director (Non-Nurse) is responsible for maintaining patients' clinical records, including coding, auditing, and staff education on recordkeeping procedures. This position serves as the designated Privacy Officer for the facility.

Responsibilities

• Audit and complete ongoing review of all 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 coding
• Use CPT/HCPCS coding systems
• Effectively communicate with physicians, nursing staff, and allied health personnel
• Interview, hire, train, evaluate, counsel, and supervise medical records staff
• Exhibit excellent customer service and a positive attitude towards patients
• Absorb and evacuate patients as needed
• Demonstrate dependable, regular attendance
• Concentrate and use reasoning skills and good judgment
• Communicate and function productively on an interdisciplinary team
• Sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours

Requirements

• Demonstrate knowledge of State and Federal legal requirements relating to documentation, confidentiality, and legal issues pertaining to health information
• Demonstrate efficient usage of complex computer software systems
• Functional knowledge in field of practice
• Make independent decisions when circumstances warrant such action
• Knowledgeable of medical records practices and procedures as well as the laws, regulations, and guidelines governing medical records functions in the post-acute care facility
• Implement and interpret the programs, goals, objectives, policies, and procedures of the medical records department
• Perform proficiently in all competency areas including but not limited to: medical coding, auditing, clinical records, privacy official responsibilities, supervisory responsibilities, patient rights, and safety and sanitation
• Maintain confidentiality of all proprietary and/or confidential information
• Understand and follow company policies including harassment and compliance procedures
• Displays integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training
• Actively implements the compliance program and Code of Conduct and ensures 100% participation by department staff
• Participate in and promote a culture of integrity, maintain an “open door” policy, and do not participate in or allow retaliation against those who report good faith concerns