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Director of Medical Records
Heather Hill Healthcare Center

Location: New Port Richey, Florida
Work Setting: Long Term Care
Job Function:
Coder, Coding – QA, Coding Supervisor/Manager, Compliance, HIM Director/Privacy Officer, HIM Manager/Supervisor, HIM Specialist, Patient Accounts, Physician Practice Manager, QA / QI / QM, Release of Information Specialist, Other
Job Type:
Salary Range: $13.00 – $21.00


This position maintains the medical records for the facility in accordance with policies and procedures established for the medical record keeping, under the guidance of the Health Information Consultant.

Job Description

• Assure that the resident is properly registered in the necessary indices of the facility (i.e. Resident Number Register and Master Patient Index).
• Code admission diagnoses according to the ICD-10 CM coding guidelines and principles and enter codes into appropriate system(s), as required.
• Assure the admission summary (face sheet) is complete.
• Upon discharge, check records quantitatively to assure completeness and accuracy within thirty (30) days of the discharge or in accordance with state regulations.
• Determine whether additional transfer data is needed and request from transferring facility if needed. Follow-up to assure receipt.
• Check the record quantitatively on admission and periodically to assure completeness, accuracy and internal consistency. Report trends to the QA/QAPI committee.
• Communicate with and assist the medical staff and allied health personnel in updating records.
• Maintain the flow of the reports to the records.
• Update diagnostic lists as changes occur by coding additional diagnoses documented by physician and resolving inactive diagnoses. Review diagnostic lists for accuracy in conjunction with the MDS schedule and sign for accuracy of MDS Section I, as required.
• Check the discharge documentation quantitatively to assure completeness, accuracy, and internal consistency.
• Obtain complete and accurate records within thirty (30) days of discharge or in accordance with state regulations.
• Assure face sheet discharge information is correct.
• Assure all required reports are in the record.
• Follow appropriate procedures for closing a record permanently incomplete, if required.
• Maintain the Resident Number Registry.
• Verify the accuracy of the Master Resident Index upon admission and discharge of the resident.
• Maintain overflow records.
• Maintain a tracking system for physician visits and the authentication of orders.
• Maintain accurate and timely Medicare certifications, as required.
• Collect, correlate and maintain statistical data as needed.
• Provide information, when requested, to those involved in research projects and studies with the approval of center administrator.
• Assist the medical staff by providing data from the health records for Utilization
• Review, Triple Check, QAPI and various audits.
• Maintain the numerical filing system for records.
• Maintain the unit numbering system for record identification.
• Maintain the necessary sign-out and follow-up controls of records.
• Maintain and control release of information to authorized persons.
• Type and/or transcribe reports of correspondence according to the needs of the HIM department.
• Attend facility meetings as required.
• Orientation of new staff members to the HIM department. Orientation and training of nursing and ancillary departments involved in documentation process. This will involve both state and Federal regulations and center policies and procedures, as well as documentation recovery education.
• Ensure medical record copies are provided per policy and/or regulation to the appropriate resident and/or resident representative.
• Ensure medical record copy fees are charged and collected per policy.
• Ensure legal medical record requests are copied, prepared neatly, reviewed prior to delivery and sent/delivered in the specified time frame.

• Responsible for the evaluations, scheduling and disciplinary action of health information employees within the department.
• Determination of budgetary needs for both routine and capital expenditures, in conjunction with the administrator.
• All other duties as assigned.

Required Qualifications

• Ability to establish procedures and to suggest changes for smoother operations.
• Able to understand the Medical Record Systems, including filing and electronic medical records.
• Understand and utilize medical terminology, ICD-10-CM coding principles, concurrent and discharge analysis procedures, medical legal aspects, and possess management skills for a nursing facility.
• Possess personal attributes to include professionalism, neatness, accuracy.
• Must present a professional appearance.
• Must be able to cooperate and work well with fellow employees.
• Must be knowledgeable of computer systems, system applications, and other office equipment.
• Must be able to meet all local health regulations and pass pre/post-employment physical exam, if required. This requirement also includes drug screening, criminal background investigation, and reference inquiry.
• Minimum of 3-5 years of management or supervision in the field of medical records, preferably in a nursing home setting.

Preferred Qualifications

• Certification as Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).
• Active member of the American Health Information Management Association (AHIMA)
• Evidence of maintaining continuing education (CE) requirements of the American Health Information Management Association.

Education Qualifications

• High school graduate or equivalent.


Benefits offered: Paid time off, Health insurance, Dental insurance, Other types of insurance, Retirement benefits or accounts

Instructions for Resume Submission

Please email all resumes to the Administrator, Shelby Scott, at We are thrilled to read you resume and hopefully meet you!

Apply Online:

Posted: June 4, 2019 at 8:40 AM
Post ID: 39964

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