Medical Records

Director Of Medical Records - Woodward Hills Health and Rehab

Schedule: Monday-Friday 8:30am-5:00pm

POSITION SUMMARY

The Director of Medical Records assumes responsibility and accountability for the record keeping and storage of all clinical records in a manner consistent with Facility policies and procedures, professional standards and state and federal laws and regulations for long term care facilities. Manages the employees in the Medical Records department. Establishes and implements policies to ensure that records are complete, accurately documented, readily accessible and systematically organized. Collaborates with the Nursing Home Administrator to allocate department resources in an efficient manner to achieve department objectives.

MINIMUM QUALIFICATION STANDARDS

EDUCATION:

High school diploma or equivalent. LICENSE: Current certification as an CPC, CCS, RHIT from AAPC or AHIMA are preferred.

EXPERIENCE:


One year experience as a medical record practitioner in a long-term care Facility.

Deep understanding of anatomy, medical terminology, pathophysiology, and coding guidelines.

PERFORMANCE REQUIREMENTS :

Knowledge, skills, and abilities to perform the essential functions of the job.

Proficiency with Electronic Health Record (EHR) systems and coding software.

Successful performance of this job classification can best be achieved through consistent application of current knowledge, use of good judgement, common sense, ability to establish and carry out priorities, effective use of interpersonal skills and ongoing communication with residents, staff, families, interdisciplinary team members and government officials including State surveyors and ombudsmen.

ICD-10 coding. Applying ICD-10 CM codes to diagnoses, procedures, and services for billing and tracking.

PSYCHOLOGICAL REQUIREMENTS:

This job cannot be performed without exposure to the stresses associated with an intimate, 24-hour residential care environment that delivers care and services primarily to disabled and cognitively impaired residents with an average age of 78 years. Examples of these stresses include, but are not limited to shift rotation, weekend and holiday duty, usual or impaired behavior by residents, family reactions to having a loved one in the nursing home, death and dying, oversight by State surveyors, presence of consultants and variable involvement of medical staff.

PHYSICAL AND ERGONOMIC REQUIREMENTS:

Functions are carried out in a variety of positions including standing and sitting. To meet resident's needs, virtually all positions require the ability to move freely through the building. Stooping, bending, lifting, pushing, pulling, and carrying, as well as other physical demands may be required.

PHYSICAL DEMANDS

• MOBILITY: Able to physically respond quickly to emergency situations. Able to freely move arms, hands, and legs.
• LIFTING: Able to lift from 5 pounds to 40 pounds without restriction.
• CLIMBING/BALANCING: Able to climb stairs quickly. Must have good center of balance while performing physical tasks.
• STOOPING/BENDING: Able to stoop and bend frequently throughout day.
• PUSHING: Able to push residents in wheelchairs and Geri-chairs.
• STANDING/SITTING: Stands and/or walks approximately 2 hours per day. Sits approximately 6 hours per day.
• REACHING: Able to reach above head for retrieving supplies. Must have full range of motion in shoulder joints for reaching.

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