ESSENTIAL FUNCTIONS:

Oversee and assist with data collection, storage, retrieval, assembly, analysis, filing and retention of medical records/data. Implement and maintain processes and systems to ensure accurate and complete medical record documentation. Maintain department productivity, quality and efficiency for all processes within the department. Oversee and assist with discharge records analysis for practitioner deficiencies and data for accuracy, compliance and timeliness. Work with physicians to improve the quality of documentation. Report practitioner trends and audit results to the Performance Improvement Committee. Complete HIM department audits including HBIPS, CMS Quality Measures, and concurrent reviews. 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. Prepare and analyze clinical data for research purposes, process improvement, utilization management, mandatory reporting, and more. 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 CPT coding classifications. Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation. May act as a liaison with legal and compliance on audits and court engagements related to HIM. Work as liaison between facility and transcription vendor to ensure high quality, accurate, complete and timeliness of transcribed documents.

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.  Two or more years' experience managing/supervising a medical records department required. One or more years’ behavioral health experience preferred. Knowledge and understanding of the CMS IPFQR (Inpatient Psychiatric Facility Quality Reporting) Program measures, documentation and reporting requirements required. Knowledge and understanding of The Joint Commissions HBIPS measures, documentation and reporting requirements required.

 

LICENSES/DESIGNATIONS/CERTIFICATIONS:

RHIT required or ability to obtain within six months of hire date. Certified RHIA preferred.