HIM Director/Coder

Description

SUMMARY:

This position manages the Medical Records Department in accordance with the policies and procedures to maintain medical records for use in patient care, medical/legal purposes, research or study. Oversees ongoing activities related to the development, implementation, maintenance of, and adherence to the organization’s policies and procedures covering the privacy of, and access to, patient health information in compliance with federal and state laws and the healthcare organization’s information privacy practices.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

May include, but is not limited to the following:

Job Specific

• Analyzes clinical documentation to accurately assign codes for primary and secondary diagnoses and co-morbidities, suggesting  modifications as necessary
• Processes physician authorized diagnosis changes per approved procedures.
• Provides insight and guidance to clinical staff in determining accurate diagnosis and evaluation/management visit codes.
• Provides excellent customer service to patients, personnel, Medical, Clinical, and Ancillary department staff and adheres to KRMC Behavioral Expectations Agreement. 
• Oversight of organization-wide medical record functions to include coordination of access to, accuracy, and timely record completion.
• Serves as the organization Privacy Officer. Responsible for knowledge of applicable federal and state privacy laws and maintenance of organization privacy policies and procedures. Works with administration, legal counsel, facility departments, and other related parties to address privacy issues and ensure compliance with privacy practices.
• Assures license and accreditation standards are met. Monitors and reports quality improvement processes.
• Responsible for staff and physician related education regarding medical record functions including coding, release of information, applications and use of the electronic patient record.
• Create and maintain departmental job descriptions, policies and procedures. Direct management and evaluation of activities of staff. Conducts regular departmental meetings and in-services.

QUALIFICATIONS:

Education:

• A.S. / A.A.S.in HIT.  Bachelor’s degree is highly preferred.

License/Certification:

• Certification as an RHIA is required. Current Basic Life Support (BLS) CPR certification through the American Heart Association.  Certifications must be maintained throughout employment.

Experience:

• Must have 3-5 years of experience as a Director or Assistant Director at an Acute Care Hospital required. Experience with the Cerner or Meditech EMR required. 

SUPERVISORY RESPONSIBILITIES:

• HIM Analyst

OTHER REQUIREMENTS:

Participates in or conducts company-wide sponsored training to safeguard against improper use and disclosure of patient’s protected health information.  Monitors and ensures compliance with company policies, procedures, state and federal regulations and Accreditation Standards.

Company Specific:

• Adheres to dress code, appearance is neat and clean and wears appropriate identification while on duty.
• Adheres to all smoking or tobacco regulations established by corporate building owners, state or federal laws.
• Completes annual health, safety, and education requirements.  Maintains professional growth and development.
• Maintains confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected.
• Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patient population served.
• Reports to work on time as scheduled; adheres to policies regarding notification of absence.
• Attends all mandatory in-services and staff meetings.
• Represents the organization in a positive and professional manner.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department.
• Maintains current license/certification for position.
• Consistently demonstrates superior customer service skills to patients, physicians, visitors, employees, and any other individuals with whom they may come in contact.
• Consistently follows departmental and hospital Health, Safety, Security, Hazardous Materials policies and procedures.
• HIPAA: Conduct job responsibilities in accordance with HIPAA privacy laws, follow hospital policy in provision of patient confidentiality. Able to identify patient confidentiality issues and reports to proper hospital personnel immediately.
• Compliance: Conducts job responsibilities in accordance with standards set forth in Code of Conduct, policy and procedures, applicable federal and state laws, and applicable standards.

Core Values:
Professionalism –To always maintain the highest standard and regard for others.  Keep skills, competencies and required licensures/certifications current; displays mastery over attitude and behavior and pride in appearance. Consistently performs duties to the best of abilities.

Exceptional Care—Go above and beyond expectations by providing exceptional care to WOW our customers—patients, family, physicians, and each other.

Respect – Treating others as they would like to be treated; valuing others. Acknowledges the worth of others through professional greetings, proper telephone etiquette, patience, and common courtesy.

Fun - Having fun and celebrating small successes in our journey to achieve big.  Always demonstrates a positive attitude toward work and devotion to our passion and task at hand.

Teamwork –To function as a unit, with common goals, recognizing we can achieve far more as a team than as individuals.  Cooperates with co-workers while performing duties leading to everyone being able to achieve success and giving recognition where it is due.

Integrity – To always be honest and trustworthy in all our relationships.  Demonstrates adherence to a strict moral or ethical code in performance of duties by always seeking to do the right thing.

Accountability - Responsibility of our actions that influence the lives of our customers and fellow workers.  Takes ownership of all aspects of duties shown through reliable, timely performance and responsibility.

Responsibility – Maintains accountability by doing what is expected or beyond; assuring the appropriate tasks and project items are completed. Takes ownership of all aspects of duties shown through reliable, timely performance and accountability.

Knowledge/Skills/Abilities:

• Excellent oral and written communication and interpersonal skills.
• Ability to work under stress and to respond quickly in emergency situations.  Ability to work cooperatively as a member of a team.
• Demonstrates good interpersonal skills when working or interacting with patients, their families and other staff members.
• Ability to communicate in English effectively through verbal and written means to the extent necessary to perform job duties appropriately.  Reading and comprehension at level necessary to perform job duties appropriately.
• Understands the principles of growth and development for the entire lifespan and ability to provide care appropriate for adult and geriatric patients as appropriate to the patient population.
• Ability to maintain confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected.

Disclaimer:

This description is designed to indicate the general nature and level of work for this position.  It is not intended to describe minor duties or other responsibilities that may be periodically assigned.

Qualifications