Description

Medical Records DirectorSHIFT: Full-Time, Monday - Friday 8am - 4:30 pm

Job Summary:Maintains the integrity of the medical records from admission to discharge and final storage.

Job Responsibilities:

• Completes admission paperwork (facility specific)

• Computes admission/discharge face sheets upon admission and updates upon re-admission according to policy guidelines

• Requests specific medical information on a resident as needed from other facilities, MD, hospitals, etc.

• Reponsible for updating paperwork for any and all changes related to room changes, physician changes or contact information changes

• Assigns a code for all diagnosis: ICD-10 coding of the Admission/Discharge Record, Medicare determination forms

• Audits all active medical records on the nursing units for accuracy and completeness 14 days after admissions and re-admissions. 14-day chart audit policy is to be followed for long term residents

• Ensures that discharge summaries are completed according to policy on each planned discharge

• Closes all permanent discharge medical records according to policy and final chart analysis procedure

• Notifies Administrator/DON and all appropriate disciplines of any deficiencies found in either active or closed charts

• Retrieves and copies medical records as required promptly per policy and bills accordingly

• Notifies Administrator of all requests for information from medical records

• Protects all medical record information from loss, defacement or destruction before retention period ends

• Assures that all medical record information is protected and kept confidential

• Compiles the Dental/Podiatry/Optometry list and distribute to appropriate disciplines

• Maintains residents' rights

• Maintains HIPAA privacy, security, and confidentiality

• All other duties assigned by Administrator

Requirements:

• High School diploma or GED

• Valid NYS Driver's License

• Medical Records Experience

• Excellent organizational, communication, and decision-making skills

Benefits:

• Paid Time Off (PTO)

• Health, Vision, and Dental Insurance

• Life Insurance

• Referral Bonus Program

• Weekly or Same Day Pay Options

• Supportive Work Environment

Apply today and become a key part of our team in maintaining a comfortable, safe environment for residents and staff alike!

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)