DIR - HIM/MEDICAL RECORDS

UHS•Casper, WY

11d

About The Position

The Director of Health Information Management (HIM) is responsible for directing the HIM Service Department in accordance with all established standards from regulatory and licensing agencies. This role involves consulting with management, administration, and medical staff to ensure patient records meet these standards, and maintaining the confidentiality of medical records by releasing files only to authorized entities. The Director will also inform staff about confidentiality policies, stay current on relevant laws and regulations, and manage departmental staff through hiring, firing, and maintaining rosters. A key responsibility is monitoring the accuracy and maintenance of medical records for compliance with state agencies, TJC, and Medical Staff Bylaws. This position serves as a liaison with other HIM departments, handles inquiries, and oversees subpoenas and legal requests related to medical records in coordination with Risk Management. The Director will monitor chart coding, abstract patient information for state agencies, and coordinate the preparation and revision of medical record forms to ensure compliance with TJC, federal and state laws, and Bylaws. This role chairs the HIM Forms Committee and prepares statistical reports for administration. The Director will also participate in or lead management and committee meetings, assist in data abstraction for medical care evaluation studies, and monitor the quality of transcription services. Staying current on HIM laws and ensuring the continuous professional development of self and staff through professional activities is crucial. The role requires meeting AHIMA requirements for accreditation and staying abreast of changes in the field. Identifying and addressing the educational needs of staff, professional staff, and other personnel through planning and teaching classes is also part of the role. A professional attitude and support for the facility's guest relations philosophy are expected, along with adherence to all facility policies, procedures, mandatory in-services, and standards for conduct, dress, attendance, and punctuality. The Director will support quality/performance improvement goals and maintain confidentiality of employee and patient information. A critical skill is the ability to accurately abstract ICD 10 codes for inpatient/outpatient accounts with a strong understanding of medical terminology.

Requirements

Associate’s Degree (RHIT) or Bachelor's Degree (RHIA) in Health Information Management
A minimum of three (3) years’ supervisory experience in health information management is required
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.
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).

Nice To Haves

Direct experience in a health care psychiatric facility

Responsibilities

Direct the Health Information Management Service Department within all standards established by regulatory and licensing agencies.
Consult with management, administration, and medical staff to ensure that all patient records are maintained within standards established by licensing agencies.
Maintain confidentiality of medical records, ensuring the release of files and/or records to only appropriate and authorized authorities.
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.
Direct department staff members, ensuring effective organization and completion of tasks.
Ensure effective departmental staffing, which may include hiring, firing, and maintaining staff rosters relative to changing facility needs.
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.
Function as a liaison with other hospital facility Health Information Management departments.
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.
Monitor the coding of all discharged patient charts, and abstract all pertinent patient information for forwarding to state agencies, as required.
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.
Chairs the Health Information Management Forms Committee and/or submit all forms to the Health Information Management Records Committee for review.
Prepare as requested statistical reports for administration.
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.
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.
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.
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.
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.
Adhere to facility, department, corporate, personnel, and standard policies and procedures.
Attend all mandatory facility in-services and staff development activities as scheduled.
Adhere to facility standards concerning conduct, dress, attendance, and punctuality.
Support facility-wide quality/performance improvement goals and objectives.
Maintain confidentiality of facility employees and patient information.
Able to abstract ICD 10 (or subsequent ICD Version) codes accurately for inpatient/outpatient accounts with a thorough knowledge of medical terminology.