1
Director of Medical Records
JOB DESCRIPTION
Position Title:
Director of Medical Records
Exemption Status:
Exempt
Job Classification:
Job Code:
Department:
Reports to:
Last Update:
Job Summary
The ideal candidate will be responsible for successfully managing the organizational and administrative operation of the Medical
Records Department.
Essential Functions
• Promotes the mission, vision, and values of the organization
o Establishes, reviews, and updates short and long-term goals in order to be consistent with hospital wide plans and to
achieve the goals and strategic plan of RGH
o Establishes specific and necessary planning ,control and performance improvement mechanisms that monitors
patient care, administrative and economic outcomes
• Directs the overall activities of the Medical Record Department by:
o Establishing specific & necessary planning;
o Maintaining, training and evaluating sufficient staff;
o Developing and maintaining control mechanisms that monitor patient care and administrative and economic
outcomes.
• Directs the activities of personnel under their supervision.
o Maintains sufficient, trained staff to adequately fulfill the requirements of the department.
o Organizes department hierarchy/structure in a manner that results in efficiency, effectiveness and responsiveness.
o Maintains a sensitive, fair, and impartial approach to dealing with employees
o Develops and maintains channels of two-way communication with employees and performs departmental in-service
training
o Establishes and monitors standards of performance among all subordinates and ensures that standards are being
consistently met
o Improves subordinate performance through ongoing counseling, coaching, delegation, and feedback practices
o Conducts department-wide meetings to maintain two-way communication, problem solving, and information
passing
• Directs the essential functions of the Medical Record Department, including but not limited to:
o Performs internal chart audits
o Maintains an appropriate turnaround time for coding, transcription and release of information.
o Ensures the quality of medical records by verifying their completeness, accuracy, and proper entry into computer
systems.
2
o Develops processes, preferably through E.H.R system, to transfer patient records to other health care providers and
other facilities and ensure that appropriate requests and authorizations are completed.
o Codes or supervises coding for all patient types, both in-house and out-sourced. Provides sufficient training and sets
standards of proper coding to retain maximum reimbursement. Directs coding audits as necessary.
o Maintains specific and necessary controls to ensure confidentiality of patient medical records. Strictly adheres to
HIPAA policies and performs or supervises the duties of the HIPAA Officer
o Represents the hospital in court cases involving subpoena of medical records
• Assumes the responsibility for successfully fulfilling standards and criteria of licensing and accrediting agencies
o Stays abreast of regulatory requirements, coding and reimbursement changes.
o Maintains regulatory requirements including all state & federal regulations related to HIMS and, as appropriate, to
the facility.
• Interacts with other departments within the hospital to ensure the quality and completeness of patient medical records.
o Reports delinquent medical records to administration in coordination with the medical staff bylaws
o Interact positively with members of the medical staff by cultivating liaisons and promoting interaction
o Attends meetings, prepares reports and analyzes and provides recommendations in a timely and accurate manner
• Recognizes the importance of financial responsibility and develops a budget for the department.
o Develops comprehensive realistic annual budgets that reflect departmental needs based on external and internal
environments and the application of cost-effective management.
o Develops and determines annually a capital budget for administrative approval.
o Consults with CFO of any significant changes in budget requirements.
Non-Essential Functions
• Perform other duties as assigned.
Professional Requirements
• Adhere to dress code, appearance is neat and clean.
• Complete annual education requirements.
• Maintain patient confidentiality at all times.
• Report to work on time and as scheduled.
• Wear identification while on duty.
• Maintain regulatory requirements, including all state, federal and local regulations.
• Represent the organization in a positive and professional manner at all times.
• Comply with all organizational policies and standards regarding ethical business practices.
• Communicate the mission, ethics and goals of the organization.
• Participate in performance improvement and continuous quality improvement activities.
• Attend regular staff meetings and in-services.
Qualifications
• Registered Health Information Administrator or Registered Health Information Technician
• Minimum of five years’ experience in Health Information Management, preferably in a hospital setting
• Extensive knowledge of HIPAA required
• Knowledge of state regulations for hospital facilities preferred
• Basic computer knowledge.
• Previous hospital experience preferred.
• Electronic medical record knowledge.
• Previous EHR administration experience preferred.
• Coding knowledge ICD-10
Knowledge, Skills, and Abilities
• Knowledge of health information management services.
• Strong organizational and interpersonal skills.
• Ability to determine appropriate course of action in more complex situations.
• Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude.
• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work.
• Ability to maintain confidentiality of all medical, financial, and legal information.
• Ability to complete work assignments accurately and in a timely manner.
• Ability to communicate effectively, both orally and in writing.
• Ability to handle difficult situations involving patients, physicians, or others in a professional manner.
3
• Ability to use computer applications to assemble and analyze patient data
Physical Requirements and Environmental Conditions
• Work is performed during regular work hours.
• Work in varying degrees of temperature (heated or air conditioned).
• Work under extreme pressures.
• Position requires sitting for approximately 4-6 hours per day and walking for 2 hours per day.
• Position requires light to moderate work with 50 pounds maximum weight to lift and carry.
• Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and
seeing.
General Sign-off
The employee is expected to adhere to all agency policies and to act as a role model in adherence to agency policies.
The above statements are intended to describe the general nature and level of work being performed. They are not intended to be
construed as an exhaustive list of all responsibilities.
I have read, understood and had the opportunity to ask questions regarding this position description.
_______________________________ ____________________________
Employee’s Signature Date