Director of Health Information Services

Gogebic Medical Care Facility•Wakefield, MI

1d•Onsite

About The Position

This role is responsible for managing health information services, ensuring compliance with policies and procedures, and maintaining the accuracy and completeness of resident medical records. The position involves supervision of staff, coordination of quality assurance initiatives, and acting as a gatekeeper for various government and in-house computer systems. The Director will also be responsible for IT issue resolution, transcription, coding, and maintaining all aspects of the medical record system, from admission to discharge and retention.

Requirements

Associate Degree in medical records or related field, or equivalent work experience.
Be certified as a Registered Health Information Technician or be eligible for certification.
Experience in transcription and medical terminology and ICD-10-CM Coding.
Comply with all Facility policies and procedures.
Comply with all policies and procedures as may be established by your supervisor.
Comply with all safety, universal precautions and infection control policies and procedures.
Prompt and regular attendance.

Nice To Haves

Minimum of two years’ experience in the medical record field.
Minimum of one-year experience in a supervisory capacity.
Computer Support.
Billing Support.
Corporate Compliance Officer Designee.
Nursing Administrative Assistant Designee.
Will act as Privacy and Security Officer for HIPAA.

Responsibilities

Communicate effectively in person, on the telephone, and in writing.
Be proficient in the operation of computers and dictation equipment.
Comply with all Facility policies and procedures, including safety, universal precautions, and infection control.
Present a friendly, calm, cooperative, and positive manner.
Arrive to work as scheduled and consistently demonstrate dependability and punctuality.
Obtain continuing education relating to the requirements of health information technology.
Maintain licensure as a Registered Health Information Technician (National Credential).
On occasion may need to lift up to 40 lbs.
Assist with MDS data entry.
Coordinate and oversee Quality Assurance and QAPI meetings.
Provide appropriate medical record reports to the Quality Assurance Committee & QAPI.
Supervise and support daily needs of facility Ward Clerk(s).
Transcribe physician dictation to include resident’s history and physical, discharge summary, progress notes, correspondence and reports.
Assign medical record number to resident & maintain established numbering system for record identification.
Maintain resident records to assure completeness, accuracy and internal consistency for the current and discharged resident.
Code resident diagnosis according to ICD-10-CM on admission and update as needed.
Maintain Computerized Master Resident Index & Residents Register according to the needs of the facility, following the established nomenclature and classification systems.
Setup & act as gatekeeper for various Gov't Websites (i.e. CHAMPS, Matrixcare, Webdenis, etc.).
Act as gatekeeper for IN-HOUSE computer programs i.e. ECS, Outlook, MS Office, SupplyHawk, Policy Stat, Accushield, Retail Tracker, Dial-My calls, Cloud Badging, MS-365 Management Console, UP Rehab/NetHealth, Alibi Surveillance Camera System, VISIONLINK/COMPASS Alarms Systems, NGS Medicare Connex LSO (Local Security Officer) etc.
Act as gatekeeper for NHSN.
Address all I.T. issues as they occur throughout Facility for all departments (this is 24-7) – this includes but is not limited to ECS charting software, Matrixcare EF/Res Med/Time Tracker/Retail Tracker, Accushield, Up Rehab Net Health, ePremis, MS Office 365 Admin Suite, Policy Stat, Cloud Badge Program, Dial-My-Calls program.
Setup monthly round for AveleCare (formerly Telehealth Solutions) Physician – using Webside Connect website scheduling app. (This can also be more often than monthly.)
Download & Submit monthly meter readings to CBS for Multi-Function Printers.
Download progress notes from AveleCare (formerly THS) Web Portal.
Communicate & coordinate monthly rounds by AltoPiano Medical Associates. Also enter visit/rounding dates and download progress notes when needed.
Maintain filing system for records.
Maintain secondary record systems.
Maintain overall control and preservation of records.
Maintain record retention log and supervise destruction of records.
Maintain and control the release of information of medical records.
Update HIS Department policies and procedures.
Update resident information in nursing computer.
Assemble admission record and record information on admission card; initiate all required forms for the resident chart.
Review resident records for concurrent analysis and quality assurance purposes.
Review contents of the medical record and purge according to procedures.
Assemble the “closed medical record” upon resident discharge and death.
Fax messages to physicians, pharmacy, and other agencies as needed.
Maintain physician visit schedule and Medicare Daily Documentation Form.
Maintain confidentiality.
Shred confidential papers.
Assist in maintaining list of residents on chemical restraints monthly.
Fax Medicare certification and recertification forms to physicians.
Maintain Facility Form Book.
Support Hilltop Herald.
Maintain Facility Signature/Initial Form.
Participate/develop in-services re: Medical Records and HIPAA & Computer Programs/Systems.
Requisition supplies, as needed.
Maintain a clean, orderly, and safe work environment.
Immediately report malfunctioning or unsafe, or suspected malfunctioning or unsafe, equipment or conditions to supervisor.
Attend and/or instruct required in-services.
Attend required meetings.
Other duties may be assigned.