Medical Records Director (750157)

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

B. 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 employee in this position is responsible and accountable for the planning, supervision, direction, and administration of the Medical Record Department. The functions of the department include medical record assembly, analysis, coding, transcription, filing, correspondence, and confidentiality of all medical records at Clarks Summit State Hospital. The employee works under the supervision of the Quality Assurance Risk Management Coordinator.

Description of Duties

The Medical Records Director directly supervises Medical Records Assistants (MRAs).

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.

Maintains working knowledge of current operating 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 operating requirements.

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.

Plans, organizes, and directs work within the department by developing objective goals; prioritizing projects; and assigning, reviewing, and evaluating the subordinates' work efforts in order to ensure a systematic review of the department.

Manages the maintenance of all patient records by ensuring completion, providing proper storage, and confidentiality of patient information in order to maintain records according to acceptable HIPAA, DHS, OMHSAS and all accreditation/ certification agency standards.
Conducts ongoing review/monitoring addressing this standard. Serves as the hospital's HIPAA Privacy Officer. The Medical Records Director immediately reports identified, suspected, or potential breaches of confidentiality to the PI-RM Coordinator.

Manages the hospital's statistical reporting system by generating the Daily Patient Census, monthly, quarterly, semi-annual, and yearly reports as well as other reports as requested. This work requires a high degree of accuracy with few to no errors.

Serves as the lead person for the development and implementation of the Hospital's electronic medical records system, to remain in compliance with state, federal, and accreditation standards.

Maintains an awareness of current medical record technology to ensure timely improvements are implemented.

Updates the Medical Record Department Manual by reviewing present policies/procedures and revising as necessary as well as developing new policies/procedures in order to clarify work and maintain consistent practice within the department.

Manages the department's human resources by monitoring leave time; completing performance evaluations and progress review; administering, counseling, and ensuring attendance of staff at relevant Staff Development programs in order to comply with standards set forth by DHS and in conjunction with union contracts.

Communicates with peers and subordinates by conducting Clarks Summit State Hospital and Medical Record Department in-services and personnel meetings on a designated or as needed basis, in order to orient staff to medical records as well as discuss and convey relevant information to staff.

Conducts ongoing performance improvement activities by monitoring patient records, environments, statistics and other relevant documents in order to provide quality of care/service and ensure compliance with all applicable accreditation/certification agency standards.

Manages the department's material resources by using supplies in accordance with DHS rules in order to ensure supplies are used appropriately and in a cost-efficient manner.

Attends assigned Clarks Summit State Hospital committee meetings by representing the Medical Record Department in order to participate and share input into decisions relating to or effecting medical records or the department.

Manages the inventory and location of all forms that are filed in the medical record.
Serves as a form consultant for any new or revised forms which are filed in the medical record.

Attends in-service and out-service training by participating in assigned courses and other job related training in order to maintain certification with AHIMA (American Health Information Management Association) and to comply with standards set by DHS.

Performs other related duties and special projects as assigned. Purpose and standards will be given at the time of each assignment.

Essential Functions:

1. Develops, institutes, and maintains policies relevant to the medical record functions.

2. Professionally communicate in a clear, effective manner with all parties through any communication method

3. Clearly expresses ideas and information, both orally and in writing

4. Establishes and maintains effective working relationships with facility staff, patients and other involved parties.

5. Directs and trains subordinate staff in the provision of medical records functions

6. Operates various office machines such as typewriters, copiers, computers, transcription equipment, fax machines, etc.

7. Strictly adhere to requirements regarding accessing, using, and disclosing work-related information

8. Ambulate distances internally and externally as needed to conduct routine work assignments

9. Obtains and maintains crisis response/intervention certification from the approved Commonwealth vendor, CPR certification, and appropriately utilizes skills.

Decision Making

General direction, consistent with duties inherent to this position, is provided by the Quality Assurance Risk Management Coordinator and the Quality Assurance Risk Management Director. Other specific assignments are made by the supervisor as deemed appropriate or necessary. The work is reviewed periodically by the Quality Assurance Risk Management Coordinator and the Quality Assurance Risk Management Director by means of individual conferences, consultations, and written reports.

The employees are assigned ongoing work consistent with their job descriptions and responsibilities. Special assignments and projects are made on an as-needed basis. Special assignments are reviewed upon completion. Ongoing work is reviewed by

means of individual conferences, consultations, and written reports.

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.

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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