Responsibilities
POSITION SUMMARY
The Director of Health Information Management Services is responsible for directing the activities of the Health Information Management Services Department in the management and maintenance of all patient medical records information, ensuring compliance will all state and federal laws, rules/regulations of licensing agencies and within TJC standards for the quality of patient care.
Qualifications
Education: Associate’s Degree (RHIT) or Bachelor's Degree (RHIA) in Health Information Management
Experience: A minimum of three (3) years’ supervisory experience in health information management is required, with direct experience in a health care psychiatric facility preferred. Thorough knowledge of medical records, release of information, ICD 10 coding Inpatient/Outpatient, the coding rules and regulations and DRG assignments and state and federal regulatory standards required.
Licensure: Certification accreditation as a registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT), as determined by the American Health Information Management Association (AHIMA).
Primary Responsibilities
- Direct the Health Information Management Service Department within all standards established by regulatory and licensing agencies.
- Consult with management, administration, and medical staff to ensure that all patient records are maintained within standards established by licensing agencies.
- Maintain confidentiality of medical records, ensuring the release of files and/or records to only appropriate and authorized authorities.
- Inform all facility staff of confidentiality policies pertaining to medical records, and remain current on all laws and regulations regarding confidentiality of patient/medical information.
- Direct department staff members, ensuring effective organization and completion of
- Ensure effective departmental staffing, which may include hiring, firing, and maintaining staff rosters relative to changing facility needs.
- Monitor the accuracy and appropriate maintenance of medical records on every patient, ensuing compliance with rules and regulations of state agencies, TJC on Accreditation of Health Organizations, and Medical Staff Bylaws.
- Function as a liaison with other hospital facility Health Information Management departments.
- Respond to inter-departmental and external inquiries and questions. Oversees all subpoenas and other legal requests pertaining to medical records. Monitor the coding of all discharged patient charts, and abstract all pertinent patient information for forwarding to state agencies, as required.
- Coordinate the preparation and/or revisions to medical record, forms, ensuring compliance with all requirements of TJC, applicable state and federal laws, Bylaws and Rules/Regulations.
- Chairs the Health Information Management Forms Committee and/or submit all forms to the Health Information Management Records Committee for review.
- Prepare as requested statistical reports for administration.
- Participate in, or lead various management and/or committee meetings as assigned. Assist in the abstraction and analysis of data from the medical record for medical care evaluation studies, patterns of patient care and Performance Improvement. Monitor the quality of the transcription services offered by the department, to ensure accuracy and timeliness.
- Remain current and up to date on all laws regarding Health Information Management. Ensure the continuous professional development of self and staff, by attending professional meetings, seminars, and training.
- Meet the requirements of the American Health Information Management Association in assuring not only active accreditation but a means of keeping abreast in the ever-changing field of Health Information Management Services.
- Identify the educational needs of the Department Staff, the Professional Staff and other personnel and assist in the planning and teaching of classes as needed.
- Demonstrate a professional attitude and support the objectives of the facility's guest relations philosophy through internal and external communications and interactions with all levels of staff, patients, family members, guests, and community and referral sources.
- Adhere to facility, department, corporate, personnel, and standard policies and procedures.
- Attend all mandatory facility in-services and staff development activities as scheduled.
- Adhere to facility standards concerning conduct, dress, attendance, and punctuality.
- Support facility-wide quality/performance improvement goals and objectives.
- Acts as the facility’s Privacy Officer.
- Maintain confidentiality of facility employees and patient information.
- Able to abstract ICD 10 codes accurately for inpatient/outpatient accounts with a thorough knowledge of medical terminology.
Note: The essential job functions of this position are not limited to the duties listed above.
Qualifications
KNOWLEDGE, SKILLS, AND ABILITIES
THIS SECTION DESCRIBES WHA T KNOWLEDGE, SKILLS AND ABILITIES AN EMPLOYEE IN THIS POSITION SHOULD CURRENTL Y POSSESS. THIS LIST MAY NOT BE COMPLETE FOR ALL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED FOR THIS POSITION.
- Knowledge of laws, rules and regulations of federal/state agencies, TJC, and Medical Staff Bylaws regarding medical records management.
- Knowledge of policies and procedures regarding the management and confidentiality of patient
- Knowledge of computers and various software programs.
- Thorough knowledge of medical records coding and medical terminology.
- Skill in organizing and prioritizing workloads to meet deadlines.
- Skill in telephone etiquette and paging procedures.
- Effective oral and written communication skills.
- Ability to communicate effectively with patients and co-workers.
- Ability to adhere to safety policies and procedures.
- Ability to use good judgment and to maintain confidentiality of information.
- Ability to work as a team player.
- Ability to demonstrate tact, resourcefulness, patience and dedication.
- Ability to accept direction and adhere to policies and procedures.
- Ability to recognize the importance of adapting to the various patient age groups (child, adolescent, adult and geriatric).
- Ability to work in a fast-paced environment.
- Ability to meet corporate deadlines.
- Ability to react calmly and effectively in emergency situations.
PHYSICAL, MENTAL, AND SPECIAL DEMANDS
MODIFICATIONS TO THE MANNER IN WHICH THIS JOB MAYBE PERFORMED WILL BE REVIEWED ON A CASE BY CASE BASIS.
- Ability to work a 40-hour week.
- Ability to sit for long periods, up to 8 hours.
- Ability to move flexibly is required in filing and retrieving medical records.
- Ability to use both hands in fine manipulation of small tools (copier, computer, telephone, typewriter, calculator, facsimile machine).
- Ability to push and pull up to 10 Ibs. (file cabinet drawers, computer paper boxes).
- Ability to see well enough to read handwritten and typewritten material.
- Ability to lift and carry up to 25 Ibs. to move/transfer file boxes and data processing paper.
- Ability to stoop, kneel, and bend daily to retrieve files from bottom shelves and drawers and to move boxes of paper and forms to computer printer.
- Ability to reach, turn, and twist above and below the waist daily to retrieve files from top shelves to get office supplies from upper shelves in supply closet.
- Ability to spend 90% of working time in an environment of continuous low voices and office machine noise typical for business office atmosphere.
- Ability to handle a variety of repetitive tasks.
