JOB TITLE/POSITION: Medical Records Manager

 

Reports to: Clinical Director/Director of Patient Care Services

 

JOB DESCRIPTION SUMMARY: Responsible for managing all aspects of maintaining and protecting the organization’s clinical records, including managing the clinical records team.

 

ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES:

1. Manages all daily clinical records functions, including establishing and implementing clinical records policies.

2. Ensures clinical record systems comply with state, federal, and Joint Commission regulations.

3. Maintains comprehensive working knowledge of state, federal, and Joint Commission documentation regulations and is a resource for appropriate organization personnel.

4. Protects all clinical records by establishing and implementing control procedures for all open and closed records.

5. Protects the confidentiality of patient and organization information through adequate controls and direct supervision of clinical records.

6. Forwards copies of clinical records to authorized users according to policy.

7. Completes an administrative record audit following patient discharge and forwards the record to the Clinical Supervisor/Nursing Supervisor for clinical audit.

8. Monitors aged unsigned physician orders and submits second and third requests for signed orders to overdue physicians, calls, or visits to the offices of seriously delinquent physicians.

9. Supervises the use of the clinical records information system and maintains a comprehensive working knowledge of the system, including upgrades and enhancements.

10. Recruits, selects orients and manages members of the clinical records team.

11. Manages the members of the clinical record team to ensure accurate and prompt filing and retrieval of clinical records. The above statements are intended to be a representative summary of the primary duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

 

QUALIFICATIONS: Bachelor’s degree is a must in any health-related field. At least two years’ experience in clinical records management preferably in hospice care operations. Information systems knowledge required. Demonstrated ability to supervise and direct clerical personnel. Knowledge of corporate business management, governmental regulations and 
Joint Commission standards. Demonstrates good communication skills and public relations skills. Demonstrates autonomy, organization, assertiveness, flexibility and cooperation in performing job responsibilities.