Pacific Villas Post Acute in
Medical Records Director
Pacific Villas Post Acute in, Oceanside, California, United States, 92058
Overview
Medical Records Director (Healthcare) Responsibilities include receiving and following work schedules and supervisor instructions, assisting in organizing and directing the medical records department in accordance with established policies and procedures, and supporting the Medical Records/Health Information Consultant as required. The role also involves maintaining meeting minutes, filing as necessary, fostering good working relationships with interdepartmental and facility staff, and assisting with incident/accident recording. Other duties include retrieving resident records (manually/electronically), delivering records as needed, and filing information such as nurses\' notes, resident assessments, progress notes, laboratory reports, x-ray results, and correspondence into resident charts. The role requires collecting, assembling, checking, and filing resident charts, assisting the MDS Coordinator with scheduling assessments in line with current facility and OBRA guidelines, and ensuring incomplete records are returned for correction. Additional responsibilities cover developing procedures to ensure records are properly completed, assembled, coded, signed, and indexed before filing; establishing controls to prevent unauthorized removal of charts/records; maintaining a record of information released from charts (recipient, date, department, etc.); abstracting information for insurance, Medicare, Medicaid, VA, and similar entities in accordance with privacy rules; indexing medical records as directed; maintaining registries (e.g., admission and discharge); transcribing and typing physician reports as needed; and coordinating chart intake, completion, and order. The position also involves collecting charts, assembling them in proper order, inspecting for completion, and transporting records between wards, nurses\' stations, and designated areas as necessary.
Other operational duties include batch processing resident information into the computer, retrieving demographic information, answering telephone inquiries, preparing written correspondence, and ensuring only authorized personnel access records. The role must ensure proper sign-out/sign-in of records, file active/inactive records according to policy, and maintain confidentiality of resident information. The incumbent agrees not to disclose access credentials or resident information and to report suspected violations to the Administrator; report unauthorized attempts to access the information system; and assume administrative authority and accountability for assigned duties. Committee and supervision duties include performing secretarial tasks for facility committees, collecting and compiling records for committee review, and preparing reports as directed. Personnel functions involve reporting known or suspected fraud, enforcing security measures such as logging off unattended workstations, and supporting staff development. The role requires supervising staff, maintaining census and status changes, and participating in mandatory in-service trainings (e.g., OSHA, TB, HIPAA, Abuse Prevention). Safety, sanitation, equipment, and supply responsibilities include reporting unsafe conditions or equipment malfunctions, replenishing supplies, and ensuring clean work areas and proper storage. Budget and planning duties require reporting suspected fraud related to false billings and cost reports. Additional duties may be assigned as needed. Supervisory requirements: this position has direct reports. Qualifications
Education and/or Experience:
Must possess a minimum of a high school diploma or GED. Typing speed of at least 45 words per minute and use of dictation equipment. Working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc. is preferred but not required. On-the-job training provided in medical record and health information system procedures. Must be knowledgeable of medical terminology and computers, data retrieval, input, and output functions. Language Skills:
Ability to read, write, speak, and understand English. Ability to read technical procedures. Mathematical and Reasoning Skills:
Ability to apply fractions, percentages, ratios, and proportions. Ability to make independent decisions when warranted, interact tactfully with residents, staff and the public, work harmoniously with others, minimize waste, and incorporate new methods and principles. Ability to follow written and oral instructions. Must not pose a direct threat to health or safety. Physical Demands:
Move intermittently, speak and write clearly, cope with mental and emotional stress, and meet health requirements including a medical and physical examination. Ability to push, pull, move, or lift at least 25 pounds to a height of 5 feet and carry for at least 50 feet. May assist in resident evacuation during emergencies. Work Environment:
Office and facility-wide duties; frequent interruptions; occasional extended hours, weekends, holidays, and other shifts as necessary; may be called back during emergencies. Exposure to infectious waste, chemicals, and various odors; possible encounters with hostile or upset individuals; potential exposure to hazardous chemicals and other risks. This description covers typical conditions and may change with reasonable accommodation. Additional Information:
Note: Nothing in this job specification restricts management\'s right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described above and may be subject to change due to reasonable accommodation or other reasons. The statements are intended to describe the general nature and level of work performed and are not a complete list of all responsibilities, duties, and skills required.
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Medical Records Director (Healthcare) Responsibilities include receiving and following work schedules and supervisor instructions, assisting in organizing and directing the medical records department in accordance with established policies and procedures, and supporting the Medical Records/Health Information Consultant as required. The role also involves maintaining meeting minutes, filing as necessary, fostering good working relationships with interdepartmental and facility staff, and assisting with incident/accident recording. Other duties include retrieving resident records (manually/electronically), delivering records as needed, and filing information such as nurses\' notes, resident assessments, progress notes, laboratory reports, x-ray results, and correspondence into resident charts. The role requires collecting, assembling, checking, and filing resident charts, assisting the MDS Coordinator with scheduling assessments in line with current facility and OBRA guidelines, and ensuring incomplete records are returned for correction. Additional responsibilities cover developing procedures to ensure records are properly completed, assembled, coded, signed, and indexed before filing; establishing controls to prevent unauthorized removal of charts/records; maintaining a record of information released from charts (recipient, date, department, etc.); abstracting information for insurance, Medicare, Medicaid, VA, and similar entities in accordance with privacy rules; indexing medical records as directed; maintaining registries (e.g., admission and discharge); transcribing and typing physician reports as needed; and coordinating chart intake, completion, and order. The position also involves collecting charts, assembling them in proper order, inspecting for completion, and transporting records between wards, nurses\' stations, and designated areas as necessary.
Other operational duties include batch processing resident information into the computer, retrieving demographic information, answering telephone inquiries, preparing written correspondence, and ensuring only authorized personnel access records. The role must ensure proper sign-out/sign-in of records, file active/inactive records according to policy, and maintain confidentiality of resident information. The incumbent agrees not to disclose access credentials or resident information and to report suspected violations to the Administrator; report unauthorized attempts to access the information system; and assume administrative authority and accountability for assigned duties. Committee and supervision duties include performing secretarial tasks for facility committees, collecting and compiling records for committee review, and preparing reports as directed. Personnel functions involve reporting known or suspected fraud, enforcing security measures such as logging off unattended workstations, and supporting staff development. The role requires supervising staff, maintaining census and status changes, and participating in mandatory in-service trainings (e.g., OSHA, TB, HIPAA, Abuse Prevention). Safety, sanitation, equipment, and supply responsibilities include reporting unsafe conditions or equipment malfunctions, replenishing supplies, and ensuring clean work areas and proper storage. Budget and planning duties require reporting suspected fraud related to false billings and cost reports. Additional duties may be assigned as needed. Supervisory requirements: this position has direct reports. Qualifications
Education and/or Experience:
Must possess a minimum of a high school diploma or GED. Typing speed of at least 45 words per minute and use of dictation equipment. Working knowledge of medical terminology, anatomy and physiology, legal aspects of health information, coding, indexing, etc. is preferred but not required. On-the-job training provided in medical record and health information system procedures. Must be knowledgeable of medical terminology and computers, data retrieval, input, and output functions. Language Skills:
Ability to read, write, speak, and understand English. Ability to read technical procedures. Mathematical and Reasoning Skills:
Ability to apply fractions, percentages, ratios, and proportions. Ability to make independent decisions when warranted, interact tactfully with residents, staff and the public, work harmoniously with others, minimize waste, and incorporate new methods and principles. Ability to follow written and oral instructions. Must not pose a direct threat to health or safety. Physical Demands:
Move intermittently, speak and write clearly, cope with mental and emotional stress, and meet health requirements including a medical and physical examination. Ability to push, pull, move, or lift at least 25 pounds to a height of 5 feet and carry for at least 50 feet. May assist in resident evacuation during emergencies. Work Environment:
Office and facility-wide duties; frequent interruptions; occasional extended hours, weekends, holidays, and other shifts as necessary; may be called back during emergencies. Exposure to infectious waste, chemicals, and various odors; possible encounters with hostile or upset individuals; potential exposure to hazardous chemicals and other risks. This description covers typical conditions and may change with reasonable accommodation. Additional Information:
Note: Nothing in this job specification restricts management\'s right to assign or reassign duties and responsibilities to this job at any time. Critical features of this job are described above and may be subject to change due to reasonable accommodation or other reasons. The statements are intended to describe the general nature and level of work performed and are not a complete list of all responsibilities, duties, and skills required.
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