Medical Records Director

Medical Records Director Job Description

The Medical Records Director plays a vital role within a healthcare organization, responsible for managing and overseeing the organization's Medical Records department. This role requires exceptional organizational skills, attention to detail, and knowledge of medical terminology and regulations. The Medical Records Director plays a critical role in maintaining the accuracy, security, and confidentiality of patient information while ensuring compliance with legal and regulatory requirements.

Medical Records Director Responsibilities

1. Develop and implement policies and procedures for maintaining and managing Medical Records in compliance with relevant laws, regulations, and accreditation standards.
2. Manage and supervise the Medical Records department staff, including hiring, training, and evaluating performance.
3. Oversee the organization and maintenance of all patient Medical Records, ensuring proper documentation, confidentiality, and accessibility.
4. Implement effective record-keeping systems, including electronic health record (EHR) systems, to ensure efficient retrieval and management of patient information.
5. Collaborate with healthcare providers and other departments to ensure accurate and complete documentation of patient diagnoses, treatments, and outcomes.
6. Monitor and evaluate Medical Records practices to identify opportunities for improvement and implement changes to enhance efficiency, accuracy, and compliance.
7. Develop and enforce protocols for record retention, release, and destruction, ensuring compliance with legal and regulatory requirements.
8. Stay up-to-date with changes in medical record regulations, coding practices, and technology to ensure compliance and optimal performance.
9. Respond to inquiries and requests for Medical Records from authorized individuals or organizations, while safeguarding patient confidentiality and privacy.
10. Collaborate with IT professionals to ensure the security and integrity of electronic health records, including data backup, disaster recovery, and cybersecurity measures.

Medical Records Director Required Skills

1. Strong knowledge of medical terminology, coding systems (such as ICD-10 and CPT), and healthcare documentation requirements.
2. Excellent organizational and time management skills, with the ability to prioritize and manage multiple tasks and deadlines.
3. Proficient in electronic health record (EHR) systems and other healthcare software applications.
4. Strong attention to detail and accuracy, with the ability to review and analyze complex Medical Records for completeness and compliance.
5. Excellent communication and interpersonal skills, with the ability to effectively collaborate and communicate with healthcare providers, staff, and external entities.
6. Knowledge of legal and regulatory requirements related to medical record management, including HIPAA and other privacy laws.
7. Strong leadership and management skills, with the ability to motivate and supervise a team.
8. Analytical and problem-solving skills, with the ability to identify process improvement opportunities and implement solutions.
9. Ability to adapt to new technologies and stay updated on industry trends and best practices.
10. Commitment to maintaining patient confidentiality and privacy.

Required Qualifications

1. Bachelor's degree in Health Information Management or related field. A master's degree is preferred.
2. Certified Health Information Management Professional (CHIM) or Registered Health Information Administrator (RHIA) certification is preferred.
3. Minimum of 5 years of experience in medical record management, with at least 2 years in a supervisory or managerial role.
4. In-depth knowledge of medical record regulations, privacy laws, and coding systems.
5. Proficiency in using electronic health record (EHR) systems and other healthcare software applications.
6. Familiarity with accreditation standards, such as those set by The Joint Commission or the Commission on Accreditation of Rehabilitation Facilities (CARF).
7. Strong understanding of healthcare documentation requirements and best practices.
8. Excellent computer skills, including proficiency in Microsoft Office Suite.
9. Ability to maintain professionalism and exercise discretion when handling sensitive and confidential information.
10. Strong commitment to continuous learning and professional development in the field of Medical Records management.