JOB SUMMARY

Responsible for managing all aspects of maintaining and protecting organization clinical records including the management of the clinical records team.

DUTIES & RESPONSIBILITIES

• Manages all daily clinical records functions including establishing and implementing clinical records policies.
• Ensures clinical record systems are maintained in compliance with state, federal and regulations.
• Maintains comprehensive working knowledge of state, federal regulations and serves as a resource for appropriate organization personnel.
• Protects all clinical records through the establishment and implementation of control procedures for all open and closed records.
• Protects the confidentiality of patient and organization information through effective controls and direct supervision of clinical records.
• Forwards copies of clinical records to authorized users according to policy.
• Completes an administrative record audit following patient discharge and forwards abnormal results to the Clinical Director or their designee for clinical audit.
• Monitors aged unsigned physician orders and submit second and third requests for signed orders to overdue physicians, calls or visit the offices of seriously overdue physicians.
• Supervises the use of the clinical records information system and maintains a comprehensive working knowledge of the system including upgrades and enhancements.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by the employee of this job.  The employee may be requested to perform job-related tasks other than those stated in this description.

JOB REQUIREMENTS (Education, Experience, Knowledge, Skills & Abilities)

• At least three years of 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 and governmental regulations 
• Demonstrates good communication skills and public relations skills.
• Demonstrates autonomy, organization, assertiveness, flexibility and cooperation in performing job responsibilities.