JOB TITLE:  HIM Manager                                                              NHA CODE:

REPORTS TO:  CFO                                                                          REVISED BY:  Carla Bazyn

POSITIONS SUPERVISED:  HIM Coordinator, Transcriptionist,            REVISED DATE:  04/12/2022

Medical Records Technician/Imaging Coordinator

CONTRACTED SERVICES MANAGED:  RuralMed

PRIMARY FUNCTION 

Responsible for:   The HIM Manager provides leadership in planning and managing all medical records services to drive effective processes that are aligned with regulations and industry standards including the following areas: Medical Record Governance, Compliance with Uses & Disclosures of PHI, medical record auditing & data validation, clinical documentation & coding.  Responsible for front-end delivery of services to patient, family, and other requests while delivering excellent customer service. Manages HIM resource requirements to ensure appropriate balance between tactical and strategic demands. Implements HIM continuous improvement programs driven by metrics and implements best practices for processes & systems. Collaborates with IT & Informatics to improve data quality and provides in-depth technical expertise for tactical and operational initiatives. Serves as facility HIPAA/Privacy Officer. (See Privacy Officer Job Description)

QUALIFICATIONS

Education and/or Experience

• Bachelor’s degree from accredited college or university (Health Information Management, Informatics, or other related technical field) PLUS seven (7) years of broad-based associated HIM/Medical Records experience, three (3) of which must have been in an Acute Care Hospital HIM/Medical Records department.

OR

• Associate’s degree from accredited college or university (Health Information Management, Informatics, or other related technical field) plus ten (10) years of broad-based associated HIM/Medical Records experience, five (5) of which must have been in an Acute Care Hospital HIM department.

Note: HIM/Medical Records experience should include work in the following functional areas: Medical Record Information Governance, Compliance with Uses and Disclosures of PHI, Revenue Cycle Management & Reimbursement Methodologies, Coding & Clinical Classification Systems, Clinical Documentation Improvement, HIPAA/Privacy with advanced/expert knowledge in several of these areas.

• 5 years of demonstrated leadership & HIM/Medical Records experience
• Master’s degree in Health Information Management, Informatics, Hospital administration, Business Administration or a related field highly desirable.
• Solid understanding of medical & anatomical terminology
• Demonstrated experience with an Electronic Health Record and related applications such as: Cerner, Meditech, Epic, Paragon, etc; experience with installation, building, testing, modifying, optimizing applications
• Must be knowledgeable in healthcare regulations for area(s) of oversight
• Ability to research complex regulatory requirements; excellent organization skills with high attention to detail
• Excellent verbal and written communications skills

Certificates, Licensure, Registrations

• Must possess AHIMA RHIT certification or obtain within 12 months of hire.
• Any of the following AHIMA certifications a plus: RHIA, CDIP, CCS, CHPS.

SIGNIFICANT DUTIES

• Medical Record Information Governance
  • Manages health record content & documentation, including defining the legal health record
  • Develop & implements policies and procedures for data management and medical record governance
  • Evaluates the integrity of health data and manages data standards based on organizational policies
  • Maintains a Master Patient Index
  • Coordinates creation, revision and standardization of medical record forms
  • Audits content & completion of the legal health record; prepares reports for administration, medical staff, committees or external organizations
• Compliance with Uses & Disclosures of PHI
  • Manage disclosure of PHI using laws, regulations and guidelines such as release of information and accounting of disclosures
  • Oversees communication & requests for information, including but not limited to patients, insurance companies, physicians/clinics & legal requests.
  • Oversees completion and/or submission of required reports and documents to state agencies, registries & other organizations (i.e., HCAPS, Death Report to NORS, maternity report and birth certificates to Vital Records Management, Paternity Acknowledgement, tumor and trauma registry updates)
  • Monitor release of information workflows
  • Determine the right of access to the legal health record
  • Ensure compliance with security & privacy initiatives and follow breach of information protocols
  • Assess health record disposition such as retention, archival, destruction
• Revenue Cycle Management
  • Code medical/health record documentation & conduct coding audits to validate accuracy
  • Assign diagnoses and procedure codes and groupings according to official guidelines
  • Monitor Discharge Not Final Billed (DNFB)
  • Educate providers on value-based programs and guidelines
  • Monitor payer clinical documentation requirements
• Clinical Documentation Improvement (CDI)
  • Collaborate with providers to clarify documentation information such as conflicting diagnoses, Present On Admission Indicators, Hospital Acquired Conditions; applies non-leading, ethical query techniques
  • Track and trend provider documentation deficiency data and compare with benchmarks
  • Perform audits of clinical documentation content to ensure compliance with institutional policies and procedures, regulations or industry standards/guidelines
  • Collaborate with medical staff leadership to promote clinical documentation improvement initiatives
  • Ensures timely completion, integrity and authenticity of medical records.
  • Develop CDI policies & procedures in accordance with AHIMA practice briefs or other appropriate standards/guidelines
  • Develop & implement training & education to facilitate documentation that supports severity of illness, risk of mortality/morbidity and utilization of resources
  • Analyzes, tracks & trends medical record data and prepares reports for the SLT, medical staff and other stakeholders; uses data to identify opportunities for improvement
• Compliance
  • Develop processes & systems that are compliant with federal and state regulatory requirements, including but not limited to the following areas: HIPAA, Data Security, Emergency Management, and Quality.
• Finance
  • Oversight of contracts & contracted work/services/deliverables in areas of oversight in collaboration with the SLT
  • Maintains, develop, monitor, and report budgets, expenses, variances
  • Maintains timekeeping records and updates appropriately and accurately for staff
  • Evaluate & justify needs and purchases; prepares and plans budgets for areas of oversight in collaboration with CFO and SLT.
• Project Management
  • Performs the role of project manager for assigned projects
  • Plans and coordinates the work of resources and team members assigned to projects
  • Manages and monitors all phases of assigned projects
  • Procures resources needed for projects
• Human Resources Management
  • Maintain and create job descriptions
  • Recruit effectively for department positions by following established hiring practices and guidelines
  • Orient new employees in a thorough manner to department and maintains related documentation.
  • Develop staff competencies, training & education programs, development plans.
  • Communicate effectively and provide feedback to staff which may include department meetings and individual employee meetings
  • Complete performance evaluations for staff, with feedback for positive reinforcement of strengths and opportunities for growth/improvement
  • Develop, support, and actively seek activities and establishes and environment that promotes recognition and retention for employees
  • Addresses employee issues in an effective & timely manner; communicates with CEO and HR regarding employee issues appropriately.
  • Enforce & interpret policies and procedures with employees
• Operational Management
  • Review, revise, develop & implement policies, procedures, plans, standards/guidelines and other documents for areas of oversight including chart completion, coding accuracy, release of information, turnaround times, workflows
  • Project Management, including development of project proposals/presentations, project goals/customer requirements, schedules, work breakdown structures, supervision of staff, communications plans, and active participation in project-based work
  • Develop & provide training programs for staff, including orientation for employees, as appropriate
  • Oversee documentation of events/incidents in accordance with policies & procedures for areas of oversight; investigate events/incidents and implement suggested remediation; identify and resolve service delivery issues.
  • Quality Management: Monitor performance of areas/programs of oversight on a continual basis and take steps to improve effectiveness
  • Serve and/or lead hospital committees, as directed

GENERAL REQUIREMENTS

1. Knowledge of HIM workflow process
2. Experience using general office equipment.
3. Excellent oral and written communication skills
4. Must be dependable, professional and a team player
5. Ability to multi-task and be flexible with job demands.
6. Maintain highest level of confidentiality at all times.