Medical Records

JOB SUMMARY

Responsible for managing all aspects of maintaining and protecting organization clinical records including the management of the clinical records team.

DUTIES & RESPONSIBILITIES

1. Manages all daily clinical records functions including establishing and implementing clinical records policies.

2. Ensures clinical record systems are maintained in compliance with state, federal and regulations.

3. Maintains comprehensive working knowledge of state, federal regulations and serves as a resource for appropriate organization personnel.

4. Protects all clinical records through the establishment and implementation of control procedures for all open and closed records.

5. Protects the confidentiality of patient and organization information through effective controls and direct supervision of clinical records.

6. Forwards copies of clinical records to authorized users according to policy.

7. Completes an administrative record audit following patient discharge and forwards abnormal results to the Clinical Director or their designee for clinical audit.

8. Monitors aged unsigned physician orders and submit second and third requests for signed orders to overdue physicians, calls or visit the offices of seriously overdue physicians.

9. Supervises the use of the clinical records information system and maintains a comprehensive working knowledge of the system including upgrades and enhancements.

10. Manages the members of the clinical record team to ensure accurate and prompt filing and retrieval of clinical records.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by the employee of this job. The employee may be requested to perform job-related tasks other than those stated in this description.

JOB REQUIREMENTS (Education, Experience, Knowledge, Skills & Abilities)

1. At least three years of experience in clinical records management preferably in home health or hospice care operations. Information systems knowledge required.

2. Demonstrated ability to supervise and direct clerical personnel.

3. Knowledge of corporate business management and governmental regulations

4. Demonstrates good communication skills and public relations skills.

5. Demonstrates autonomy, organization, assertiveness, flexibility and cooperation in performing job responsibilities.