Medical Records Director (750157)

Medical Records Director Service Statement of Work

A. Contractor shall comply with and serve as the hospital's expert for requirements related to medical records functions, including, but not limited to, the applicable requirements of the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, Medicare Claims Processing Manual, and ICD Official Guidelines for Coding and Reporting, relating to the services performed.

B. Contractor shall provide Clarks Summit State Hospital one Medical Records Director who meets the minimum experience and training requirements:

1. 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

111. 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 maintain the RHIT or RHIA credential without lapse for the period of the contracted service.

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

Position Purpose

Clarks Summit State Hospital (CSSH) is a psychiatric hospital providing inpatient psychiatric services to adults. The Medical Records Director position is an essential employee position supporting the hospital's operation.

The Medical Records Director directs the efficient operation of the Medical Records Department by effectively completing supervisory and administrative/managerial duties. The work of the Medical Records Director requires a high degree of attention to detail, accuracy, timeliness, critical thinking, efficiency, confidentiality, initiative, organization, specificity, and objectivity. Along with the other state hospitals, CSSH implemented an electronic health record (EHR) in late 2024. The Medical Records Director plays a key role in EHR data entry, in EHR data integrity, in regulation-compliant input into the EHR's design, and in the use and maintenance of the EHR.

Description of Duties

The Medical Records Director is accountable to the Chief Performance Improvement Executive (CPIE) through direct supervision by the Performance Improvement-Risk Management (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 in resolving problems within the position's scope of authority.

The work of the Medical Records Director requires effective supervision of and leadership of his/ her direct reports. The Medical Records Director directly supervises Medical Records Assistants (MRAS) and obtains Clinical Services Clerical Assistant 2 (CA2) support for the completion of Medical Records Department work as appropriate through the Clinical Services Clerical Supervisor 2.

The Medical Records Director is accountable for routinely auditing patients' charts for accuracy, completeness, and timeliness, as well as supervising MRAs in auditing patients' charts for accuracy, completeness, and timeliness.

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 his/her direct reports. The Medical Records Director is accountable for the overall operation of the Medical Records Department, for hospital-wide medical records functions, and for the accuracy, the completeness, and the timeliness of Medical Records Department work. The Medical Records Director is accountable for routinely monitoring the accuracy, the completeness, and the timeliness of all Medical Records Department work. 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' charts 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 paper active and inactive medical records; reviewing and auditing charts for conformance to requirements, such as the timeliness, the accuracy, the presence, and the 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. With implementation of the EHR, many fewer paper medical records are being created and use of paper medical records will continue to decrease with development of further EHR functions.

The Medical Records Director serves as the secondary CSSH Trusted Agent for the EHR's direct secure messaging Health Information Service Provider (HISP) and, in collaboration with the primary CSSH Trusted Agent, monitors and facilitates hospital compliance with all federal requirements related to use of direct secure messaging.

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 when indicated; cross-train direct reports to provide non-supervisory/non-administrative operations coverage; and monitor direct reports' leave use.

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 his/her direct reports 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 his/her direct reports which does not meet standards and how s/he is addressing the problem.

In consultation with the PI-RM Coordinator, the Medical Records Director interprets and executes collective bargaining contractual agreements applicable to Medical Records Department work.

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 2 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 of ficer, evaluates requests for disclosure of patient protected health information (PHI), reviews assemblages of PHI prior to disclosure, 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 paper records for closed state facilities, as assigned.

The Medical Records Director participates on or chairs 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 functions and/or the EHR.

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 serves as an Administrative Investigator and conducts investigative activities in strict accordance with a prescribed investigation process and timeframe. The Medical Records Director conducts investigative activities in a wide range of complexities with some investigations requiring extensive in-depth examination of complex, dynamic issues. The Medical Records Director conducts a wide range of investigative activities to objectively collect and preserve evidence in a focused, systematic manner. The Medical Records Director interviews patients with severe psychiatric illness who are alleged or suspected to have been abused and hospital personnel who are alleged or suspected to have abused a patient.

The Medical Records Director completes comprehensive, professional investigative reports which are accurate, clear, concise, and objective in language. The Medical Records Director professionally and objectively summarizes investigative evidence verbally at official meetings, such as panel meetings and patient grievance appeal hearings.

The Medical Records Director acts as the PI-RM Coordinator's designee as assigned in the case of absence, unavailability, or vacancy.

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

The Medical Records Director completes all other duties assigned.

Essential Functions:

1. Strictly adhere to requirements for accessing, using, and disclosing work-related information
2. Independently examine, learn, organize, prioritize, plan the execution of, and execute complex duties; function steadily and calmly in a complex, busy/fast-paced work environment with frequent interruptions
3. Independently complete work with a high degree of attention to detail, accuracy, timeliness, critical thinking, efficiency, confidentiality, initiative within the scope of authority, organization, specificity, and objectivity
4. Professionally communicate in a clear, effective manner with all parties through any communication method
5. Adhere to the details of policies, procedures, and instructions for executing work
6. Continuously apply critical thinking and reasoned/sound judgement to the execution of work, including, but not limited to, when making decisions and identifying then solving problems
7. Meet operational needs by effectively executing his/her work duties, including supervisory and administrative/managerial duties; routinely monitor the accuracy, the completeness, and the timeliness of all Medical Records Department work and consistently hold his/her direct reports accountable for meeting their performance standards
8. Independently research and learn to proficiently use all technology related to the position's duties; work primarily on a computer
9. Serve as an Administrative Investigator and conduct timely, thorough, and credible administrative investigations, including patient abuse investigations; act as the PI-RM Coordinator's designee as assigned in the case of absence, unavailability, or vacancy
10. Obtain and maintain crisis response/intervention certification from the approved Commonwealth vendor and utilize skills in accordance with training

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 his/her direct reports.

The Medical Records Director receives general direction from the PI-RM Coordinator. The Medical Records Director independently examines, learns, organizes, prioritizes, plans the execution of, and executes complex duties.

The Medical Records Director continuously applies critical thinking and reasoned/sound judgement to the exercise of independent judgement and initiative in making decisions and resolving problems within the position's scope of authority. The Medical Records Director makes decisions that comply with established operating 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.

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.

Credential Requirements

The Medical Records Director must maintain an active RHIT or RHIA credential without lapse.

D. Contractor is required to complete timely all assigned trainings including, but not limited to, trainings issued by the Commonwealth of Pennsylvania, the Department of Human Services, OMHSAS, and Clarks Summit State Hospital such as hospital-wide orientation, supervisory training, initial and annual crisis response/intervention certification training, annual training related to Medicare Part B coding, and general annual trainings.

E. Contractor is to comply with all current applicable statutes, laws, regulations, bulletins, promulgations, policies, practices, processes, certification requirements, guidelines/guidance, interpretive guidelines, benchmarks, criteria, standards, pronouncements, resolutions, elements of performance, and requirements established for similar purposes by the federal or state government, the legislature, accrediting, certifying, inspecting, auditing, and investigating entities, and CSSH.

F. Medical Records Director services are to 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 7.5 work hours per work day and 37.5 work hours per week.

i. Occasional schedule variations and/or Medical Records Director services for greater than 7.5 hours in a day and/or 37 .5 hours in a week may be required as instructed based on operational needs. Declared emergencies and on-site surveys may require the Medical Records Director to be called in from being off duty either during regular business hours or after regular business hours to report to the hospital to provide Medical Records Director or Medical Records Department services.

ii. Contractor will provide personal contact information for Contractor to be contacted if needed pursuant to section F i.

G. Contractor will timely submit any records requested pertaining to accounting of services provided to Clarks Summit State Hospital.

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