Job description

Medical Records MGR / Health Information

Job Title: Medical Records/Health Information MGR

Department: Medical Records, Health Information

Reports To: Director of Administration

Overtime Status: X Exempt ☐ Non-exempt

Job Summary:

A Medical Records Manager is responsible for managing the activities of a medical records department, including supervising staff assigned to the department.

Nature of Work

This position reports to a Director of Administration and Kamm McKenzie Partners in the office. The Medical Records Manager is responsible for ensuring that the office meets the required standards to be a successful medical records operation for an ambulatory facility. This position meets the exemption under FLSA since the primary duty is managing a customarily recognized department and customarily and regularly directing the work of at least two full time employees. Assignments are made in terms of broad goals and objectives and the incumbent must apply considerable decision-making and independent judgment in daily activities.

Primary Job Responsibilities:

1. Assembles patients’ health information including patient symptoms and medical history, exam results, X-ray reports, lab tests, diagnoses, and treatment plans.

2. Reviews to ensure all forms are completed, properly identified, and signed and that all necessary information is in the manual and/or computer file in preferred style such as chronological.

3. Communicates as needed with physicians and other health care professionals to clarify diagnoses or obtain additional information.

4. Submits files/documentation to physicians and other clinicians as requested for review, quality assurance checks, and other purposes.

5. Provides charts/documents requested for use in legal actions, following patient consent/confidentiality protocols.

6. Uses practice management software to store, tabulate, analyze and retrieve data to improve patient care, control costs, respond to surveys, or use in research studies.

7. Protects patients’ health information for confidentiality, authorized access for treatment and data security.

8. Manages and coordinates a system for safeguarding and updating active and inactive patient medical records.

9. Recommends and implements operating policies and procedures.

10. Monitors the accurateness of patient records and documentation of patient visits.

11. Serves as an advisor on medical records policies and consultant to the administration and Partners.

12. Maintains a referral tracking system to insure proper follow-up of patient care referred for outside consultations and imaging services.

13. Trains and supervises medical records personnel in the daily operations of the medical records department. Orients new staff to the relationship and interaction of medical records department.

14. Evaluates performance, implements corrective action on areas needing improvement or re-training. Recommends actions involving pay and employment.

15. Participates on the Compliance Committee as Privacy/Hipaa Officer and applicable committees and recommends policy changes as necessary.

16. Oversees the processing of subpoenas and depositions consistent with legal regulations.

17. Place orders for DME - pessaries, diaphragms, vaginal dilators.

18. Promote intake of referred patients (Referral facilitated via fax) – Make first contact with patient via RG or phone call – Document receipt of the referral

19. Close the loop activities – Respond to laboratory inquiries as to receipt of adverse reporting (WakeMed cytology), Report f/u to referring providers

20. Merge/inactivate duplicate accounts.

21. Import records from web based systems, clinician portals

22. Import records/ensure workflows are in place for FaxFinder

23. Print daily WakeMed Labor and Delivery logs for CD and DR.

24. Manage Rhinogram and Portal communications.

25. Manage Task notes within the EMR

26. Works with LOA staff to ensure LOA/ jury duty/medical necessity letters are completed as needed to complete patient forms – Milk donor/Biometric/Health Screening,

27. Locate and import records per providers’ special requests.

28. Performs other duties as assigned.

Performance Requirements:

Knowledge:

1. Knowledge of biology, chemistry, health, and computer science.

2. Knowledge of medical terminology and coding such as CPT and ICD codes.

3. Knowledge of legal and ethical considerations related to patient information.

Skills:

1. Skill in putting information in preferred medical record system, meeting clinic standards.

2. Skill in dealing with masses of information in organized manner.

Abilities:

1. Ability to alphabetize and put information (materials, forms, etc.) into chronological order.

2. Ability to analyze medical records for completeness and accuracy, paying attention to detail.

3. Ability to schedule time and assignments effectively.

4. Ability to competently use Microsoft Office and appropriate practice management software.

Equipment Operated: Range of medical records equipment and supplies, including computer hardware/software, manual files, and sorters.

Work Environment: Usually pleasant and comfortable offices.

Physical Requirements: “Must possess the physical and mental abilities to perform the tasks normally associated with a Medical Records Health Information Manager that involves standing, sitting, bending, and reaching. May work at computer monitors for prolonged periods with danger of eye strain and muscle pain. Could cause stress if workload is heavy.”

Minimum Qualification Requirements

This position requires a high school diploma or equivalent and five years of progressively responsible relevant experience. College coursework or vocational/technical training in nursing or another health-related field may substitute on a year-for-year basis for the required experience.

Preferred: Certification as an Accredited Record Technician by the American Record Association and two years of progressively responsible relevant experience.

Or Certification as a Registered Record Administrator by the American Medical Record Association and one year of responsible relevant experience.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Supplemental pay types:

• Bonus pay

Ability to commute/relocate:

• Raleigh, NC 27609: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Medical records: 2 years (Preferred)

Work Location: One location

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