Medical Records Director

Key Responsibilities:

Documentation Management:

Filing lab results, x-rays, and reports, and maintaining the master patient index.

EHR and Data Entry:

Entering demographic, diagnosis, and treatment information into the facility's EHR system.

Audit and Compliance:

Auditing records to ensure 98% or higher accuracy, completeness, and compliance with federal/state regulations.

Information Release:

Handling, verifying, and processing requests for medical records from authorized parties, families, and insurance companies.

Support Services:

Providing clinical and administrative support to the nursing department by ensuring charts are available and updated for staff.

Admission/Discharge:

Processing documentation for incoming and departing residents.

Requirements Education:

High school diploma/GED is the minimum, but certificates or associate degrees (e.g., in Health Information Management) are preferred.

Experience:

Previous experience in a medical office or clerical setting is highly desired.

Certifications:

While not always required, certifications like the Registered Health Information Technician (RHIT) from AHIMA or Certified Electronic Health Records Specialist (CEHRS) from NHA can enhance employability.