Medical Records Director

Riyadh Hospital

Duties & Responsibilities:

• Ensure that medical records are complete, accurate, and conform to standard medical records practices.
• Improvise medical policies and procedures in compliance with the accreditation standards.
• Comply with CBAHI standards, CCHI standards, ICD-10, ICD-11, ACHI, Clinical Documentation Improvement, and Integrity national and international guidelines.
• Compile statistical information and registers pertaining to the medical records department, ancillary services, and other hospitals statistical information.
• Monitor and document the requisition of supplies for the department.
• Provides diagnosis codes to the fiscal services department on a timely basis to expedite the filing of insurance claims for patient services rendered as required by hospital and external agencies.
• Participate in budget development of medical and central supplies.
• Develop and implement policies and procedures for documenting, storing, and retrieval of health information.
• Ensures documentation of the formal requests sent by the departments in case of malfunctioning equipment and defective instruments in the unit.
• Supervise the delivery of quality care as evidenced by adequate services and staff coverage on every unit.
• Laboratory and imaging services are available to meet the needs of patients.
• Review medical records; assemble into standard order and file in designated areas according to an applicable alphabetic filing system.
• Supervise and monitor the release of confidential information in accordance with rules and regulations.
• Organize department hierarchy/structure in a manner that results in efficiency, effectiveness, and responsiveness.
• Processes legal medical documents, insurance data, and corresponding requests along with appointment settings for residents.
• Develop and maintain quality improvement reports.
• Maintain patient case files including progress notes, evaluations, recommendations, charted weekly progress notes, and quarterly summaries.
• Review charts of discharged residents and develop procedures for correction of incomplete documentation.

Qualification & Experience Requirements:

• Bachelor s Degree in healthcare information management or Health Information Management Certification with a clinical background (AHIMA or equivalent).
• Master s degree is preferred.
• Minimum 5 years of experience as Medical Records Director.

Skills and Competencies:

• Knowledge of regulations established by the Saudi Commission for Health Specialties related to healthcare practices.
• Strong organizational and interpersonal skills.
• Expertise in hospital medical-records practices including medical records ethics, classification, nomenclature & health information management services.

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