DIR - HIM/MEDICAL RECORDS

Responsibilities

DIRECTOR of HEALTH INFORMATION MANAGEMENT

1. Direct the Health Information Management Service Department within all standards established by regulatory and licensing agencies.
2. Consult with management, administration, and medical staff to ensure that all patient records are maintained within standards established by licensing agencies.
3. Maintain confidentiality of medical records, ensuring the release of files and/or records to
   only appropriate and authorized authorities.
4. 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.
5. Direct department staff members, ensuring effective organization and completion of
6. Ensure effective departmental staffing, which may include hiring, firing, and maintaining
   staff rosters relative to changing facility needs.
7. 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.
8. Function as a liaison with other hospital facility Health Information Management departments.
9. Respond to inter-departmental and external inquiries and questions. Oversees all subpoenas and other legal requests pertaining to medical records in conjunction with Risk Management and UHS instructions and mandates.
10. Monitor the coding of all discharged patient charts, and abstract all pertinent patient information for forwarding to state agencies, as required.
11. 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.
12. Chairs the Health Information Management Forms Committee and/or submit all forms to the Health Information Management Records Committee for review.
13. Prepare as requested statistical reports for administration.
14. 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.
15. 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.
16. 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.
17. 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.
18. 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.
19. Adhere to facility, department, corporate, personnel, and standard policies and procedures.
20. Attend all mandatory facility in-services and staff development activities as scheduled.
21. Adhere to facility standards concerning conduct, dress, attendance, and punctuality.
22. Support facility-wide quality/performance improvement goals and objectives.
23. Maintain confidentiality of facility employees and patient information.
24. Able to abstract ICD 10 (or subsequent ICD Version) codes accurately for inpatient/outpatient accounts with a thorough knowledge of medical terminology.

Qualifications

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).

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).

DIRECTOR of HEALTH INFORMATION MANAGEMENT

1. Direct the Health Information Management Service Department within all standards established by regulatory and licensing agencies.
2. Consult with management, administration, and medical staff to ensure that all patient records are maintained within standards established by licensing agencies.
3. Maintain confidentiality of medical records, ensuring the release of files and/or records to
   only appropriate and authorized authorities.
4. 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.
5. Direct department staff members, ensuring effective organization and completion of
6. Ensure effective departmental staffing, which may include hiring, firing, and maintaining
   staff rosters relative to changing facility needs.
7. 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.
8. Function as a liaison with other hospital facility Health Information Management departments.
9. Respond to inter-departmental and external inquiries and questions. Oversees all subpoenas and other legal requests pertaining to medical records in conjunction with Risk Management and UHS instructions and mandates.
10. Monitor the coding of all discharged patient charts, and abstract all pertinent patient information for forwarding to state agencies, as required.
11. 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.
12. Chairs the Health Information Management Forms Committee and/or submit all forms to the Health Information Management Records Committee for review.
13. Prepare as requested statistical reports for administration.
14. 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.
15. 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.
16. 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.
17. 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.
18. 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.
19. Adhere to facility, department, corporate, personnel, and standard policies and procedures.
20. Attend all mandatory facility in-services and staff development activities as scheduled.
21. Adhere to facility standards concerning conduct, dress, attendance, and punctuality.
22. Support facility-wide quality/performance improvement goals and objectives.
23. Maintain confidentiality of facility employees and patient information.
24. Able to abstract ICD 10 (or subsequent ICD Version) codes accurately for inpatient/outpatient accounts with a thorough knowledge of medical terminology.