DIR - HIM/MEDICAL RECORDS

Responsibilities

REPORTS TO: 

Chief Financial Officer

SUMMARY STATEMENT & PURPOSE

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 Joint Commission standards for the quality of patient care.

All employees are expected to be pleasant, respectful, and courteous in all interactions with patients, families, staff, and visitors of the Hospital, as well as being a positive representative of INBH at all times.

MINIMUM QUALIFICATIONS

• Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).
• Thorough knowledge of medical records coding and medical terminology
• A minimum of three (3) years leadership experience in information management

PREFERRED QUALIFICATIONS

• Direct experience in a psychiatric health care facility
• Bachelor’s Degree or an Associate’s degree in information management/medical records preferred, or equivalent combination of education and experience.

Qualifications

SPECIFIC PERFORMANCE RESPONSIBILITIES

All functions are essential functions unless otherwise noted.

The job functions of this position are not limited to the duties listed below.

1. Perform personnel management duties including screening and selection of designated staff, providing department orientation and training, schedule management, completing performance evaluations, address performance issues, and provide feedback to Human Resources.
2. Direct the Health Information Management Service Department within all standards established by regulatory and licensing agencies.
3. Consult with management, administration and medical staff to ensure that all patient records are maintained within standards established by licensing agencies.
4. Maintain confidentiality of medical records, ensuring the release of files and/or records to only appropriate and authorized authorities.
5. Direct department staff members, ensuring effective organization and completion of assignments.
6. Monitor the accuracy and appropriate maintenance of medical records on every patient, ensuing compliance with rules and regulations of state agencies, Joint Commission on Accreditation of Health Organizations, and Medical Staff Bylaws.
7. Function as a liaison with other corporate facility Health Information Management departments.
8. Oversees all subpoenas and other legal requests pertaining to medical records.
9. Monitor the coding of all discharged patient charts, and abstract all pertinent patient information for forwarding to state agencies, as required.
10. Coordinate the preparation and/or revisions to medical record, forms, ensuring compliance with all requirements of Joint Commission, applicable state federal laws, Bylaws and Rules/Regulations of corporate facilities.
11. Respond to inter-departmental and external inquiries and questions.
12. Submit all forms to the Documentation Task Force (or Forms Committee) for review.
13. Prepare as requested statistical reports for administration and outside agencies.
14. Monitor the quality of the transcription services offered by the department, to ensure accuracy and timeliness.
15. Assist in the abstraction and analysis of data from the medical record for medical care evaluation studies, patterns of patient care and Performance Improvement.
16. Serves as INBH Privacy Officer

PHYSICAL & SENSORY REQUIREMENTS, WORK ENVIRONMENT & CONDITIONS:

• Ability to work at least 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 lbs. (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 lbs. 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.