Medical Records Director Resume Samples

Description :

1. Reviews medical records for completeness, assembles records into standard order, and files records in designated areas according to an applicable alphabetic filing system.
2. Operates a computer to enter and retrieve data and type correspondence and reports.
3. Answer telephones and give information to callers, take messages, or transfer calls to appropriate individuals.
4. Make copies of correspondence and other printed material.
5. Greet visitors and callers, handle their inquiries, and direct them to the appropriate persons according to their needs.
6. Order nursing and medical supplies weekly to ensure the staff has all the equipment and supplies needed to aid in the resident's daily care.
7. Order uniforms and required non-slip shoes for facility and staff.
8. Provided a phenomenal first impression to potential residents and family members by giving facility tours featuring amenities and clinical support.

Experience

7-10 Years

Level

Management

Education

HT

Description :

1. Admissions and discharges, daily/monthly census, state submissions, and knowledge of the wide variety of computer systems that are used within healthcare organizations.
2. Developed and implemented policies and procedures for documenting, storing and retrieval of health information while upholding and the following facility.
3. Processed legal medical documents, insurance data and corresponding requests along with appointment setting for residents to see the physician.
4. Supervised staff in preparing and analyzing medical documents.
5. Coordinated medical care documentation while developing criteria and methods for such evaluations alongside other staff to ensure quality care and safety.
6. Analyzed patient data for reimbursement, facility planning and quality of care, risk management, and keeping all data current for all registries.
7. Assisted on floors with resident meals, cares and transfers as needed.

Experience

5-7 Years

Level

Executive

Education

Associate

Description :

1. In charge of the admission's department and all functions related.
2. Provided tours, assessed patients for potential admissions, worked with families.
3. Assisted the Medicaid process for patients marketed our services to the public and submitted quarterly reports to the administrator.
4. Responsible for the census of the building, the overall growth of the facility, and to create new referrals, partners, and programs to increase overall volume in the company.
5. Worked with the Medical Director, local hospitals and nursing homes.
6. Building rapport and trust with all those around me was a necessity in this position.
7. Working with local leaders to join together to make a better community and provide quality care.

Experience

7-10 Years

Level

Management

Education

Diploma

Description :

1. Reviews charts of discharged residents for the deficient information and ensures compliance for correction of deficient documentation.
2. Files resident medical information in the resident chart in a chronological way.
3. Assures that each section of the resident's record is maintained in a neat, organized and readable format.
4. Ensures that Physician's orders, telephone orders and other records requiring signatures are received and filed within the required time frame.
5. Maintains effective communication with others, both inside and outside the department, to give or obtain needed information or coordinate activities of residents.
6. Ensures that all residents are seen by their physicians, and routine lab work is completed and filed in the required time frames.
7. Ensured the patient's needs are obliged while assessing the performance of all employees.
8. Maintaining current and old charts in order and up to standards per state regulations.

Experience

5-7 Years

Level

Executive

Education

Certification

Description :

1. Maintain daily/weekly/monthly census (Admissions, Discharges, Transfers, Bed holds) and patient change of status/condition.
2. Compliance with Health Dept., Federal and State Regulations, HIPAA/PHI/Privacy Rules.
3. Oversee all functions of the Medical Records Department-Release of Information (ROI) Train and hire new staff, manage and schedule current staff per department needs.
4. QA Monitor/audit chart entries to ensure accuracy and completeness.
5. Hire, train new Medical records staff, Manage and maintain PointClickCare system Run monthly reports for MD's, RN's.
6. Handle medical record requests and put policies and procedures in place.
7. Created new guideline systems for RN's, MDs, Clinicians regarding RX, patient notes, etc.

Experience

2-5 Years

Level

Junior

Education

BBM

Description :

1. Provided in-service training to staff on confidentiality, medical records policy and procedures, changes in processes and provide annual HIPAA training.
2. Compiled statistical data and developed report/graphs.
3. Developed and implemented recurring quality improvement reports on errors and improvement processes to describe to senior management and the quality improvement committee.
4. Monitored for timely completion of all paperwork, billing tickets, and clinical documentation.
5. Served on Peer Review Committee, EHR Committee, Forms Committee, and QI Committee.
6. Reviewed medical records procedures and policy for compliance with regulatory agencies and update and rewrite policies and procedures as applicable.
7. Oversaw and managed the medical records of all 9 centers in our area.

Experience

2-5 Years

Level

Junior

Education

BS

Description :

1. Protect the security of medical records to ensure that confidentiality is maintained.
2. Process patient admission chart with face sheet and close charts of dis-enrollments, review records for completeness, accuracy, and compliance with HIPAA regulations.
3. Plan, develop maintain and operate a variety of health record indexes and storage.
4. Retrieval of medical records to collect, classify, store and analyze information.
5. Thin charts, filling information, complete monthly reports, send billing sheets and super-bills to fed ex weekly to the clearinghouse.
6. Process all release of information (ROI) medical records in a timely and efficient manner.
7. Determine correct ICD 9 code for patient diagnosis.
8. In-service staff to ensure updated knowledge of medical record policies and procedures, regulations and other facility policies.

Experience

5-7 Years

Level

Executive

Education

Certification

Description :

1. Checks new admissions for completion of required data to meet Licensing and Certification requirements, and facility policies and procedures.
2. Assembles new admission records, indexes and codes diagnosis.
3. Conducts in-house record monitoring of documentation requirements according to the audit and quality assurance system and schedules established by the facility.
4. Reviews physician progress notes for additional diagnosis, indexes, and codes diagnosis.
5. Assures maintenance of resident admission and discharge index and admission and discharge register and disease index.
6. Clear in-house records and files clearance records in discharge record order.
7. Monitors timely completion of Medicare certifications and recertifications.

Experience

10+ Years

Level

Senior

Education

BS

Description :

1. Accurately copied physician-dictated reports and complied with patient requests for copies of patient records.
2. Located, checked in and pulled medical records for incomplete patient charts.
3. Maintained and organized master Resident Index and information files in the master database.
4. Facilitated organized record retrieval and access by maintaining a filing system for both in-house and discharged residents.
5. Planned, developed, organized, evaluated and directed the implementation of the facility's resident care policies.
6. Organized charts regularly in accordance with the hospital's policy and procedures.
7. Prepared charts and maintained records of newly admitted patients.

Experience

2-5 Years

Level

Junior

Education

BS

Description :

1. Treated all patients, their families, visitors, peers, staff and providers in a pleasant and courteous manner.
2. Updated patient financial information to guarantee accuracy.
3. Answered and quickly redirected up to 100 calls per 8 hour period.
4. Answered and managed incoming and outgoing calls while recording accurate messages.
5. Helped distribute employee notices and mail around the office.
6. Performed monthly inventory and maintained office and medical supply counts.
7. Closely collaborated with the management team to make necessary improvements and satisfy resident needs.
8. Continually improved knowledge, skills, and performance-based on feedback and self-identified professional developmental needs.

Experience

10+ Years

Level

Senior

Education

Diploma

Description :

1. Concurrent and discharge medical record chart audits to ensure regulatory compliance.
2. Compile and file medical documentation accurately to ensure the completeness of the medical record in accordance with standard practices.
3. Maintain security and organization of all patient medical records in a 240-bed long facility.
4. Create standardized forms to facilitate internal and external communication.
5. Produce interdisciplinary discharge summaries on all discharged patients.
6. Transcribe physician and nursing orders accurately and completely Complete request forms, manually or via computer for blood work and x-rays.
7. Provide medical records to outside agencies in compliance with HIPAA regulations.
8. Continually improved knowledge, skills, and performance-based on feedback and self-identified professional developmental needs.

Experience

10+ Years

Level

Senior

Education

BS

Description :

1. Resolve or clarify codes or diagnoses with conflicting, missing, or unclear information by consulting with doctors or other medical personnel.
2. Protect the security of medical records to ensure that confidentiality is maintained.
3. Review records for completeness, accuracy, and compliance with regulations.
4. Process patient admission or discharge documents.
5. Reviewing all orders for accuracy and completeness and entered into the computer system correctly on a daily basis.
6. Entering admissions into the computer and all necessary orders per facility protocol.
7. Maintaining current and old charts in order and up to standards per state regulations.

Experience

0-2 Years

Level

Entry Level

Education

Vocational

Description :

1. Established client relationships; analyzed client data based on interviews, educational and medical records.
2. Participated in case reviews related to client compliance and progress treatment.
3. Determined the effectiveness of recommended counseling programs and made adjustments as needed.
4. Adhered to productivity and quality assurance standards.
5. Maintained case files including activities, progress notes, evaluations, and recommendations; charted weekly progress notes and quarterly summaries.
6. Conducted diagnostic evaluations and made appropriate recommendations.
7. Protect the security of medical records to ensure that confidentiality is maintained.
8. Review records for completeness, accuracy, and compliance with regulations.

Experience

2-5 Years

Level

Junior

Education

Associate