The Medical Records Director conducts group Medical Records Department meetings as often as needed for effective, efficient Medical Records Department operation, but no less than once each month.
The Medical Records Director consults with the PI-RM Coordinator regarding activating progressive discipline processes for his/her direct reports when activating progressive discipline processes appears to be indicated. The Medical Records Director keeps the PI-RM Coordinator apprised of work performance and work conduct by his/her direct reports which does not meet standards and how s/he is addressing the problem.
In consultation with the PI-RM Coordinator, the Medical Records Director interprets and executes collective bargaining contractual agreements applicable to Medical Records Department work.
The Medical Records Director demonstrates understanding of all activities executed by the Medical Records Department and plans effective operations coverage, in collaboration with the Clerical Supervisor 2 when applicable.
For all providers for whom the hospital bills Medicare Part B, the Medical Records Director coordinates the processes for assigning the provider's benefits to the hospital which may include, but not be limited to, activities such as enrolling the provider in Medicare, renewing the provider's enrollment in Medicare, having the provider assigned a National Provider Identifier (NPI), and/or having a provider's NPI assigned to the hospital.
The Medical Records Director proactively, continuously identifies and investigates or assesses suspected or potential deficiencies, variances, and opportunities for improvement regarding Medical Records Department functions. In accordance with established requirements, the Medical Records Director develops and leads performance improvement activities related to Medical Records
Department functions, including, but not limited to, performance improvement monitors, audits, Quality Assessment Performance Improvement (QAPI) initiatives, and hospital goals. The Medical Records Director develops materials to support performance improvement activities, including, but not limited to, corrective action plans, policies, procedures, forms, and audit/data tools. The Medical Records Director reports identified, suspected, or potential deficiencies, variances, noncompliance, and opportunities for improvement regarding non-Medical Records Department functions to the PI-RM Coordinator.
The Medical Records Director serves as the hospital's HIPAA privacy of ficer, evaluates requests for disclosure of patient protected health information (PHI), reviews assemblages of PHI prior to disclosure, and supervises the disclosure of patient PHI to authorized individuals. The Medical Records Director immediately reports identified, suspected, or potential breaches of confidentiality to the PI-RM Coordinator.
The Medical Records Director reviews requests for access to specific databases and data/ information systems, approves or denies requests in accordance with established criteria, and maintains records regarding access approvals and denials.
The Medical Records Director verifies that patients' paper medical records are properly electronically archived before authorizing shredding of the paper medical records. When patients' paper medical records are shredded in-house, the Medical Records Director verifies that the paper medical records are properly shredded before being discarded. The Medical Records Director facilitates generation of letters documenting shredding of specific medical records upon authorizing shredding of said medical records. The Medical Records Director serves as custodian of paper records for closed state facilities, as assigned.
The Medical Records Director participates on or chairs assigned workgroups and/or committees and completes tasks related to workgroup and/or committee membership.
The Medical Records Director participates in assigned hospital performance improvement activities, such as root cause analysis and failure mode effect and analysis processes, pertinent to medical records functions and/or the EHR.
The Medical Records Director provides occasional coverage for the PI-RM Department for activities such as committee meetings and environment of care rounds.
The Medical Records Director serves as an Administrative Investigator and conducts investigative activities in strict accordance with a prescribed investigation process and timeframe. The Medical Records Director conducts investigative activities in a wide range of complexities with some investigations requiring extensive in-depth examination of complex, dynamic issues. The Medical Records Director conducts a wide range of investigative activities to objectively collect and preserve evidence in a focused, systematic manner. The Medical Records Director interviews patients with severe psychiatric illness who are alleged or suspected to have been abused and hospital personnel who are alleged or suspected to have abused a patient.
The Medical Records Director completes comprehensive, professional investigative reports which are accurate, clear, concise, and objective in language. The Medical Records Director professionally and objectively summarizes investigative evidence verbally at official meetings, such as panel meetings and patient grievance appeal hearings.
The Medical Records Director acts as the PI-RM Coordinator's designee as assigned in the case of absence, unavailability, or vacancy.
The Medical Records Director adheres to the detail of prescribed policies, procedures, and his/her supervisor's instructions for completing work.
The Medical Records Director completes all other duties assigned.
Essential Functions:
The Medical Records Director is accountable for his/her work performance and work conduct, as well as the work performance and the work conduct of his/her direct reports.
The Medical Records Director receives general direction from the PI-RM Coordinator. The Medical Records Director independently examines, learns, organizes, prioritizes, plans the execution of, and executes complex duties.
The Medical Records Director continuously applies critical thinking and reasoned/sound judgement to the exercise of independent judgement and initiative in making decisions and resolving problems within the position's scope of authority. The Medical Records Director makes decisions that comply with established operating requirements, such as laws, regulations, bulletins, policies, and operational frameworks.
Some decisions, problem resolutions, and/or changes to policies, procedures, forms, etc., have the potential to impact patients, hospital departments beyond the Medical Records Department, and/or the hospital's overall operations and may require consultation with the PI-RM Coordinator and/or other hospital departments before the Medical Records Director takes action.
The Medical Records Director functions steadily and calmly in a complex, busy/fast-paced work environment with frequent interruptions.
The Medical Records Director promptly informs the PI-RM Coordinator of situations which present real or potential risk, liability, or litigation, which involve problems regarding requests by external parties, or which are beyond the Medical Records Director's scope of authority.
Credential Requirements
The Medical Records Director must maintain an active RHIT or RHIA credential without lapse.
D. Contractor is required to complete timely all assigned trainings including, but not limited to, trainings issued by the Commonwealth of Pennsylvania, the Department of Human Services, OMHSAS, and Clarks Summit State Hospital such as hospital-wide orientation, supervisory training, initial and annual crisis response/intervention certification training, annual training related to Medicare Part B coding, and general annual trainings.
E. Contractor is to comply with all current applicable statutes, laws, regulations, bulletins, promulgations, policies, practices, processes, certification requirements, guidelines/guidance, interpretive guidelines, benchmarks, criteria, standards, pronouncements, resolutions, elements of performance, and requirements established for similar purposes by the federal or state government, the legislature, accrediting, certifying, inspecting, auditing, and investigating entities, and CSSH.
F. Medical Records Director services are to be provided onsite at Clarks Summit State Hospital 08:30-16:30 Monday through Friday each week, including a 30-minute daily unpaid lunch break, for a total of 7.5 work hours per work day and 37.5 work hours per week.
i. Occasional schedule variations and/or Medical Records Director services for greater than 7.5 hours in a day and/or 37 .5 hours in a week may be required as instructed based on operational needs. Declared emergencies and on-site surveys may require the Medical Records Director to be called in from being off duty either during regular business hours or after regular business hours to report to the hospital to provide Medical Records Director or Medical Records Department services.
ii. Contractor will provide personal contact information for Contractor to be contacted if needed pursuant to section F i.
G. Contractor will timely submit any records requested pertaining to accounting of services provided to Clarks Summit State Hospital.
About Us:
TulaRay partners with clients to create staffing solutions that meet unique organizational needs. Our services are designed to reduce administrative burdens, protect your brand, and improve assignment time-to-fill. We believe that mutually successful client relationships are built on lasting quality and exceptional customer service. We pride ourselves on our uncompromising commitment to high-quality emergency management & healthcare personnel, while ensuring that our clients are taken care of with personalized attention. TulaRay manages total compliance and respectfully supports hundreds of professionals and patient-centered programs.
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