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Commonwealth of Pennsylvania |
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POSITION DESCRIPTION FOR JOB POSTING |
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Position Number: 50305873 |
Description Activated On: 8/22/2025 1:49:00 PM |
Position Purpose: Describe the primary purpose of this position and how it contributes to the organization’s objectives. Example: Provides clerical and office support within the Division to ensure its operations are conducted efficiently and effectively. 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. |
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Description of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should include the major end result of the task. Example: Types correspondence, reports, and other various documents from handwritten drafts for review and signature of the supervisor. 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. |
Decision Making: Describe the types of decisions made by the incumbent of this position and the types of decisions referred to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be referred to the supervisor. Example: In response to a customer inquiry, this work involves researching the status of an activity and preparing a formal response for the supervisor’s signature. 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. |
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Requirements Profile: Identify any specific experience or requirements, such as a licensure, registration, or certification, which may be necessary to perform the functions of the position. Position-specific requirements should be consistent with a Special Requirement or other criteria identified in the classification specification covering this position. Example: Experience using Java; Professional Engineer License Experience: Registration as a Registered Health Information Technician (RHIT) or a Registered Health Information Administrator (RHIA) with the American Health Information Management Association (AHIMA) Licenses, registrations, or certifications: 1. Registered Health Information Technician 2. Registered Health Information Administrator 3. N/A 4. 5. 6. |
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Essential Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 pounds.
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