Description

ESSENTIAL FUNCTIONS:

· Maintain department productivity, quality and efficiency for all processes within the department.

· Responsible for information governance to ensure facility-wide health data integrity, privacy, and security.

· Implement processes and systems to support accurate and complete medical record documentation.

· Oversee and assist with data collection, storage, retrieval, assembly, analysis, filing and retention of medical records/data.

· Prepare and analyze clinical data for research purposes, process improvement, utilization management, mandatory reporting, and more.

· Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation.

· Work with physicians to improve the quality of documentation.

· Work with coding staff to ensure accurate coding for reimbursement and clinical care.

· Oversee data collection, storage, retrieval, filing and retention of medical records/data.

· Audit records and data for accuracy, compliance and timeliness. Review results with administration, medical, nursing and clinical staff.

· Ensure documentation is filed in the medical records in an accurate and timely manner and ensure that the medical record is complete (including signatures) and closed within facility guidelines.

· Interface with inside/outside legal counsel regarding content of medical records.

· Work as liaison between facility and transcription vendor to ensure high quality, accurate, complete and timeliness of transcribed documents.

· Ensure HIM Key Indicators are tracked and reported monthly to the Performance Improvement Committee.

· Ensure State Reporting is accurate, complete and reported timely.

· May oversee and/or complete coding according to current ICD and/or CPT coding classifications.

· May serve as the facility Privacy Officer.

OTHER FUNCTIONS:

· Perform other functions and tasks as assigned.

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

· High school diploma or equivalent required. Bachelor’s degree with specialization in health information administration preferred.

· Four or more years' experience managing/supervising a medical record department required.

· Two or more years’ of behavioral health experience preferred.

· Working knowledge in ICD-10-PCS and DSM IV coding systems required.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

· Registered Health Information Technician (RHIT) required or ability to obtain within six months of hire date.

· Registered Health Information Administrator (RHIA) preferred.