About The Position

Responsible for strategic oversight and operational leadership of Coding, Clinical Documentation Improvement (CDI), and HIM Operations across a six-hospital integrated health system. Oversees all aspects of hospital coding operations, clinical documentation, and HIM operations, including Release of Information and Document Imaging departments. This senior role involves strategic planning, staff management, collaboration with clinicians and executives, and overseeing quality assurance and performance metrics.

Requirements

  • Bachelors (Required)
  • Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA), Registered Health Information Technician (RHIT) - State of Florida (FL)
  • Requires critical thinking skills, effective written and verbal communication skills, time management skills, decisive judgment. Must be able to work in a stressful environment and take appropriate action.
  • Proficient in basic computer skills including Microsoft Office applications, utilizing an electronic medical record system, computer-assisted-coding software and document imaging system.
  • Knowledgeable to serve as a subject matter expert on hospital health information management operations, legal and regulatory requirements.
  • Ten (10) years of experience in a healthcare setting, with a significant portion in Health Information Management (HIM), clinical coding, and/or Clinical Documentation Improvement (CDI), including five (5) years in a leadership role.
  • Bachelor's degree in Health Information Management or a related field with a strong understanding of anatomy, physiology, and medical terminology, including, but not limited to, Bachelor's in Nursing.

Responsibilities

  • Oversees the development and implementation of departmental strategy, goals, plans and standards consistent with the clinical, administrative, regulatory, and ethical requirements of the organization.
  • Ensures overall adherence to MHS policies, governmental and regulatory requirements and accreditation standards.
  • Responsible for providing operational leadership regarding the electronic medical record system and other HIM related applications, including computer-assisted coding, medical transcription and document imaging.
  • Oversees the implementation and ongoing performance of the coder intern training program.
  • Maintains strict adherence to patient confidentiality according to MHS Standards and regulatory requirements.
  • Oversees HIM custodial responsibility for the storage, release, and confidentiality of the legal medical record in both paper and electronic formats.
  • Provides professional expertise to the Privacy Department related to patient identity/fraud issues and patient requests for medical record amendments.
  • Collaborates regularly with key stakeholders in the organization to promote communication, support revenue integrity, improve business processes, ensure reliability of internal and external reporting, and promote standardization across the healthcare system.
  • Leads departmental operational and financial planning to ensure cost-efficient operations and to maximize profitability.
  • Plans, organizes, manages and facilitates various budgets for HIM and Document Imaging including capital, operating, labor, and position control.
  • Chairs the Legal Medical Record Committee and performs as an active member of various committees and work groups related to Privacy and Security, Compliance, Finance, Forms Management, Electronic Medical Record (EMR) Connect, EMR work groups, Nursing Informatics, Population Health, Quality & Patient Safety, and Revenue Cycle.
  • Ensures patient data integrity overseeing patient identity, medical transcription, document scanning, deficiency analysis, release of information, and clinical documentation integrity (CDI) program.
  • Provides leadership for hospital based inpatient and outpatient coding, clinical documentation integrity, coding and CDI education.
  • Researches and monitors industry, professional and national developments related to HIM.
  • Responsible for serving as project lead, advisor or sponsor for complex projects related to health information management operations.
  • Develops and implements policies and procedures that guide HIM and Document Imaging business processes, support the delivery of services and ensure a culture of quality and patient safety.
  • Oversees the planning and monitoring of onsite and remote staffing activities, including hiring, orienting, evaluating, disciplinary actions, productivity and quality monitoring, and staff training/education initiatives.

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What This Job Offers

Job Type

Full-time

Career Level

Senior

Number of Employees

5,001-10,000 employees

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