Under the direction of the Director of Compliance responsible for the day-to-day operations of the Medical Records department in support of the “wrap-around model” to ensure that all requests for services and information are handled in a timely manner and at the appropriate level of service. Responsible for providing guidance and leadership achieved by overseeing, coordinating and carrying out diverse and complex records management tasks. Develop and implement medical records policies and procedures. Ensure adherence to established policies, procedures, laws and regulations in compliance with HIPAA, state, federal and regulatory requirements.
- Develops, designs, implements and reviews policies and procedures for records maintenance, retention and retrieval including determination of space requirements for archived records in compliance with state and federal regulations and agency guidelines. Monitors compliance with legal requirements and updates policies and procedures as necessary.
- Executes plans for implementation of departmental services and operational and informational systems for client related data; evaluates the effectiveness of the client record program and makes recommendations for improvement.
- Establishes performance measures, initiatives and corresponding action plans to implement records department strategy.
- Reports trends regarding documentation that are outside the norm or unauthorized by organizational policy and procedure to supervisor. Establish key metrics to measure performance of department.
- Acts as internal consultant on health information management issues including release of information, confidentiality, information security, information storage and retrieval, and record retention as well as authorship and authentication of health record documentation, standardization of medical vocabularies, and use of classification systems.
- Conducts and participates in facility specific readiness assessments and gap analysis.
- As necessary, supports records personnel in carrying out day to day Records Management tasks according to policy and procedures of the department.
- Perform other duties as assigned by Administrative Director.
- Redirects requests under HIPPA to the agency’s HIPAA Privacy Officer.
- Process HIPPA related requests with signed approval from the HIPAA Privacy Officer in advance only.
- Responds to subpoenas and court orders and legal questions regarding client records. Screens subpoenas for appropriateness. Keep log of all information released. Processing all incoming requests for PHI from federal, state and/or local governmental agencies.
Data and Clinical Records Management:
- Determines feasibility and constraints applicable to design or redesign of the department’s operational systems; monitors and tracks location of medical records; compile and updates system on the status of closed records.
- Ensures that Records Retention Schedules (RRS) are applied to records and dispose of records that have met their retention period. Review record retention reports. Authorize records destruction.
- Promotes the application of filing systems and structures for the efficient organization, maintenance and use of records to facilitate retrieval and use.
- Responds to clinical staff inquiries/requests related to medical records.
- Ensures that all medical record documentation is filed correctly and timely in the designated sections of the medical record per policy and procedure.
- Responsible for updating and processing of all change of information forms including but not limited to transfers, closures, and client information changes in the agency’s electronic systems in a timely fashion and per policy and procedure.