Medical Records Director (665845) - TulaRay

Minimum Requirements:

i. Registration as a Medical Records Administrator (RHIA) with the American Health Information Management Association (AHIMA),

or

ii. Two years of experience as a Medical Records Technician (RHIT) and registration as a RHIT with AHIMA,

or

iii. Four years of experience in the preparation, classification, and abstracting of medical reports in a medical records department and registration as a RHIT with AHIMA.

Contractor shall hold an active RHIT or RHIA credential for the entire period of the contracted service.

Medical Records Director service is to include, but is not limited to:

Delivery of service 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 37.5 work hours per week. See sections G.i. through G.iv. below for occasional exceptions.

Description of Duties:

The Medical Records Director is accountable to the Chief Performance Improvement Executive (CPIE) through direct supervision and qualitative oversight by the Performance Improvement-Risk Management (PI-RM) Coordinator. The Medical Records Director performs duties as delegated and assigned by the PI-RM Coordinator. The work of the Medical Records Director is based on operational need, is heavily deadline dependent, and requires a high degree of attention to detail, accuracy, timeliness, critical thinking, efficiency, confidentiality, initiative, organization, specificity, and objectivity.

A key function of the Medical Records Director is serving as a managerial representative of hospital leadership and accomplishing work by directing his/her reporting staff/direct reports in the execution of hospital policies, leadership decisions, and hospital objectives in a productive manner.

The Medical Records Director exercises independent judgement in making decisions and resolving problems within the position’s scope of authority.

The work of the Medical Records Director requires effective supervision of and leadership of personnel under him/her in the supervisory chain of command. The Medical Records Director directly supervises Medical Records Assistants (MRAs) and one Clerical Supervisor 1. The Clerical Supervisor 1 supervises Clerical Assistant 2s who support multiple hospital departments in addition to the Medical Records Department. The Clerical Assistant 2s provide clerical support for both clinical and non-clinical operations; for example, they transcribe meeting minutes.

The Medical Records Director is accountable for his/her work performance and work conduct, as well as the work performance and work conduct of personnel under him/her in the supervisory chain of command; the Medical Records Director is accountable for the segments of hospital operations assigned to him/her, as well as those under his/her supervision. The Medical Records Director creates structure to support efficient operation in the areas under his/her supervision and to avoid productivity waste.

Some examples of the hospital’s medical records operations: abstracting patients’ medical records for diagnoses established by prescribers, for billable services rendered, and for vaccines administered; coding diagnoses established by prescribers, billable services rendered, and vaccines administered; maintaining patients’ paper active and inactive medical records; reviewing and auditing charts for conformance to requirements, such as the timeliness, accuracy, presence, and completeness of all required documents; data-related functions, such as tracking, collecting, verifying, organizing, labelling, entering, and analyzing data; copying and releasing copies of patient’s medical records; and transcribing patient medical information.

The Medical Records Director maintains working knowledge of current requirements related to the hospital’s medical records operations and makes decisions in accordance with those requirements. Some examples of types of operating requirements: laws, regulations, bulletins, policies, procedures, interpretive guidelines, standards, operational frameworks, etc. The Medical Records Director proactively and independently researches and learns applicable requirements.

The Medical Records Director proficiently interprets, applies, and continuously critically evaluates the hospital’s compliance with requirements for the hospital’s medical records operations. Some examples of specific operating requirements: Centers for Medicare & Medicaid Services (CMS) Conditions of Participation for Hospitals, Medicare Claims Processing Manual, Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), International Statistical Classification of Diseases and Related Health Problems (ICD), Health Insurance Portability and Accountability Act of 1996 (HIPAA), and ICD Official Guidelines for Coding and Reporting. The Medical Records Director facilitates the hospital’s compliance with all applicable requirements related to the hospital’s medical records operations. The Medical Records Director trains hospital personnel on medical records topics and related topics as assigned.

The work of the Medical Records Director routinely requires extensive in-depth examination of complex, dynamic issues, strict attention to detail, and application of critical thinking. The Medical Records Director independently conducts a wide variety of administrative Medical Records Department functions. Some examples of administrative functions the Medical Records Director independently conducts: developing effective Medical Records Department policies, procedures, and forms that comply with established requirements; training and instructing designated hospital personnel on topics related to Medicare billing; designing and conducting audits; developing, leading, and monitoring performance improvement activities related to Medical Records Department functions; analyzing data; and conducting complex inspections, audits, assessments, reviews, and investigations. The Medical Records Department revises Medical Records Department policies, procedures, and forms as needed to comply timely with changing requirements or to improve efficiency, but no less frequently than every three years.

The Medical Records Director interacts regularly with hospital personnel at all levels and in all departments, as well as occasionally with the hospital’s patients. The Medical Records Director interacts regularly with external entities. The Medical Records Director regularly travels throughout the hospital, including to the patient residential units, for the completion of work duties; the Medical Records Director may be on patient residential units for extended periods. The Medical Records Director functions steadily and calmly in a complex, busy/fast-paced work environment with frequent interruptions.

The Medical Records Director proficiently uses various types of technology like applications/programs and devices and independently researches and learns to use technology related to the position’s duties. The Medical Records Director uses current versions of Adobe Acrobat Pro and Microsoft Word, Outlook, Excel, PowerPoint, and Access at an advanced intermediate level for activities such as developing forms, designing data-related processes and tools, and tracking completed activities.

The Medical Records Director conducts individual supervision meetings with each of his/her direct reports as often as needed for effective performance management, but no less than once each week to review work assignments, provide instruction, and provide feedback regarding work performance. The Medical Records Director maintains documentation of individual supervision sessions.

The Medical Records Director effectively completes the full range of supervisory duties in the supervision of direct reports. Some examples of supervisory duties: assign work to direct reports; assign direct reports deadlines for the completion of work; review direct reports’ work products for completeness, accuracy, and adherence to requirements; monitor timely completion of direct reports’ work products; train, instruct, and coach direct reports; develop written procedures for direct reports’ completion of work; assess each direct report’s job knowledge, skills, strengths, and areas of need; develop a training and supervision plan for each new direct report; orient and train new direct reports; counsel direct reports regarding work performance; update direct reports’ position descriptions and performance standards annually; issue and document State Employee Assistance Program (SEAP) referrals; lead interview panels by developing performance-based candidate interview questions and assembling interview materials; conduct progress reviews and employee performance reviews when due or indicated; cross-train direct reports where appropriate to provide operations coverage; and monitor direct reports’ leave use.

The Medical Records Director completes the full range of managerial/reviewing officer duties as the manager and reviewing officer for the Clerical Supervisor 1’s subordinates by overseeing the Clerical Supervisor 1’s supervisory and performance management activities.

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 Medical Records Department personnel 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 personnel under him/her in the supervisory chain of command which does not meet standards and how s/he is addressing the problem, and/or, as applicable, facilitating the Clerical Supervisor 1 in addressing the problem.

In consultation with the PI-RM Coordinator and in collaboration with the Clerical Supervisor 1 when applicable, the Medical Records Director interprets and executes collective bargaining contractual agreements applicable to work performed in the Medical Records Department.

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 1 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 officer, evaluates requests for disclosure of patient protected health information (PHI), 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 patient medical records for closed state hospitals, as assigned.

The Medical Records Director participates on 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 and related functions.

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 completes the duties of the Clerical Supervisor 1 position if it is vacant. The Medical Records Director acts as the Clerical Supervisor 1’s designee when the Clerical Supervisor 1 is absent or unavailable.

The PI-RM Coordinator is permitted to complete the duties of the Medical Records Director’s position; however, some of the Medical Records Director’s duties are not permitted to be completed by the Clerical Supervisor 1. As such, the Medical Records Director consults the PI-RM Coordinator to plan appropriate coverage in the Medical Records Director’s absence.

The Medical Records Director acts as the PI-RM Coordinator’s designee for some of the PI-RM Coordinator’s duties in the PI-RM Coordinator’s absence.

The Medical Records Director adheres to the detail of prescribed policies, procedures, and his/her supervisor’s instructions for completing assigned work.

The Medical Records Director completes all other duties assigned.

Essential Job Functions

1. Strictly adhere to requirements regarding accessing, using, and disclosing confidential, sensitive, and/or legally-privileged information

2. Independently and proactively organize, prioritize, and plan assigned work to meet requirements for quality and timeliness; function steadily and calmly in a complex, busy/fast-paced work environment with frequent interruptions; independently develop appropriate processes for executing, auditing, and monitoring Medical Records Department work

3. Complete work with a high degree of initiative within the position’s scope, accuracy, timeliness, objectivity, specificity, and efficiency; pay strict attention to the detail of data and information; produce written work products that are grammatically correct, properly formatted and organized, professional, accurate, clear, concise, specific, and objective in language

4. Professionally communicate relevant, specific information in a clear, effective manner with all parties through any communication method while executing work duties

5. Adhere to the details of prescribed policies, procedures, and instructions for completing assigned work activities

6. Conduct in-depth examination of complex, dynamic issues; independently identify problems and develop appropriate resolutions through a process of structured analysis, critical thinking, and reasoned/sound judgment; demonstrate initiative and critical thinking in executing the assigned role within the position’s scope of authority

7. Demonstrate basic understanding of all activities executed by the Medical Records Department; meet operational needs by effectively completing assigned work and effectively executing supervisory, administrative duties, and reviewing officer duties; participate in the completion of subordinates’ work as operationally indicated

8. Use current versions of Adobe Acrobat Pro and Microsoft Word, Outlook, Excel, and Access at an advanced intermediate level; independently research and learn to use technology necessary for the position

9. Work frequently on a computer and regularly by traveling to the patient residential units; work on the patient residential units for extended periods of time

10. Act as the Clerical Supervisor 1’s designee when the Clerical Supervisor 1 is absent/unavailable; complete the Clerical Supervisor 1’s duties if the Clerical Supervisor 1 position is vacant; act as the PI-RM Coordinator’s designee for some of the PI-RM Coordinator’s duties in the PI-RM Coordinator’s absence

11. Obtain and maintain crisis response/intervention certification from the approved Commonwealth vendor and utilize skills in accordance with training

Decision Making

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 personnel under him/her in the supervisory chain of command. The Medical Records Director is accountable for the segments of hospital operations assigned to him/her, as well as under his/her supervision.

The Medical Records Director receives general direction from the PI-RM Coordinator. The Medical Records Director exercises independent judgement in making decisions and resolving problems within the position’s scope of authority. The Medical Records Director makes decisions that comply with established 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 and independently organizes and prioritizes his/her assigned work to meet standards for quality and timeliness.

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.

D. Contractor must hold an active RHIT or RHIA credential for the entire period of the contracted service.

E. Contractor shall timely complete all assigned trainings including, but not limited to, trainings issued by the Commonwealth of Pennsylvania, the Department of Human Services (DHS), the Office of Mental Health and Substance Abuse Services (OMHSAS), and Clarks Summit State Hospital.

F. Contractor shall comply with all current applicable operating requirements, such as laws, regulations, bulletins, policies, procedures, interpretive guidelines, etc. Clarks Summit State Hospital Statement of Work Medical Records Director Service

G. Except as specified in sections G.i. through G.iv. below, Medical Records Director service shall 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 37.5 work hours per week.

i. The Medical Records Director does not routinely work on holidays.

ii. Occasional schedule variations and/or Medical Records Director service in excess of 7.5 hours per day and/or 37.5 hours per week may be required as instructed based on operational need.

iii. Declared emergencies, recertification surveys, and certain types of inspections or audits may require Contractor to be called in from being off duty to provide Medical Records Director service. Such events may occur at any time of day, 365/366 days a year.

iv. Contractor may occasionally be assigned Medical Records Director work which requires Contractor to travel to other locations and work at such locations for one or more days. Some locations may be far enough away that Contractor would need to lodge overnight.

v. Contractor shall provide personal contact information for Contractor to be contacted pursuant to section G.iii above.

H. Contractor shall timely submit any records requested pertaining to accounting of service provided to Clarks Summit State Hospital.

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