Job Summary:

The Medical Records Director is responsible for directing, planning, coordinating, and administering the hospitals medical records program.

Supervisory Responsibilities:

• Manages department operations and the function of utilization review as required by public law and any other agencies.

• Supervises the checking of charts for deficiencies. Reports physicians with delinquent charts according to the medical staff bylaws. Reports incomplete and delinquent charts to the Medical Records Committee and chairperson. Distributes changes of workloads, hours, overtime hours, salary adjustments, and evaluation of employees.
• Prepares the payroll hours analysis report.

Duties/Responsibilities:

• Ensures that medical records are complete, accurate, and conform to accepted Joint Commission on Accredited Hospitals (JCAH) and state boards of health (BOH) standards, reporting to the Medical Records Committee any variations noted and new regulations or requirements, in accordance with standard medical records practices.
• Trains staff in coding, indexing, filing, preparing and displaying of information, transcription, medical terminology nomenclature and classification of diseases, and computer services including such related matters as hospital organization, goals, policies and practices, and medical records ethics, laws and regulations.
• Supervises and monitors the release of confidential information in accordance with rules and regulations.
• Compiles statistical information and registers pertaining to the medical records department, ancillary services, and other hospital statistical information as assigned or requested. Supervises and coordinates the preparation of statistical information for medical staff, medical staff committees, accreditation agencies, state agencies, and the administration.
• Participates and represents the medical records department in various hospital committees and medical staff committees as assigned.
• Appears in court when subpoenaed to testify about the authentication of medical records. Abides by the state peer review statute.
• Monitors and oversees the requisition of supplies for the department. Recommends equipment needs to ensure efficient handling of responsibilities.
• Manages computer services such as the abstracting service and the tumor registry.
• Monitors communicable diseases and reports to the state BOH through the infection control officer. Reports vital records such as birth certificates and death certificates to the state BOH (on request only).
• Provides diagnosis codes to the fiscal services department on a timely basis to expedite filing of insurance claims for patient services rendered as required by hospital and external agencies.

Required Skills/Abilities:

• Thorough knowledge of accepted hospital medical-records practices including medical records ethics, classification, and nomenclature.
• Knowledge of JCAH accreditation standards and state BOH regulations.
• Ability to interpret medical records department policies and procedures and to apply them in specific situations.
• Thorough knowledge of federal and state regulations, laws, and utilization review committee planning, organization, and management.
• Knowledge of medical staff bylaws, rules, and regulations, and the state peer review statute.

Education and Experience:

1. High school graduate or equivalent and an ART (accredited records technician) or RRA (registered records administrator) designation required.
2. Must meet required continuing education hours of the AMRA and maintain accreditation status (ART or RRA).

Physical Requirements:

• Prolonged periods sitting of at a desk and working on a computer.
• Must be able to lift up to 15 pounds at times.