Overview
Directs the activities of the HIM Department including personnel involved in maintaining permanent medical records of all hospital patients, audits and reports
Primarily responsible for coding and abstracting diagnoses, treatments and other information from patient records
Ensures that the hospital’s medical records are maintained in compliance with all accreditation and governmental regulatory agencies
Knowledge of RAC and ICD 10
Assists hospital staff by providing recorded medical information upon request
Responsibilities
- Directs, supervises and coordinates activities of personnel engaged in analyzing, compiling, coding, abstracting, and filing permanent records of patients; assists medical staff in research; prepares periodic and statistical reports; and provides information to authorized persons.
- Reviews records for completeness, accuracy, and conformance to accepted hospital accreditation standards of the Department of Health and Human Services, and the State Health Department.
- Provides an important role in the Utilization Review requirements of the Medical Staff. Compiles data for the Medical Administrative Committee. Retrieves data for medical personnel (i.e. physicians and nurses) for audits, research studies and Quality Improvement Projects.
- Prepares statistical reports for the hospital such as morbidity, birth and death reports; analysis of utilization of hospital beds according to the professional services and percentage of beds occupied; outpatient services rendered; and related data.
- Helps design forms that will be part of the medical record. Updates the accepted hospital abbreviation list when needed.
- Answers inquiries regarding information recorded in patients’ charts by correspondence or by telephone to the extent that it is allowable by law. Represents hospital in court cases involved subpoena of medical records, utilizing knowledge of principles of medical jurisprudence and laws of the state governing use of the medical records in court actions.
- Arranges for training of departmental personnel in abstracting and filling, preparation and arrangement of medical information, medical terminology, nomenclature, and classification of diseases. Outlines medical records methods and procedures and instructs personnel in medical ethics, hospital organization and management, and policies and practices of the hospital. Suggests methods for performing tasks.
- Prepares the budget for the department, including capital expenditures. Designs systems and methods to make data more accessible. Selects office equipment and supplies to be purchased for the department.
Qualifications
Required
Preferred
Education:
Must have an educational background in Health Information Management
Record Technician or a Registered Record Administrator is required
Accredited BS in HIM or related field preferred
Experience:
3-5 years management experience
Degrees, Licensure, and/or Certification:
Knowledge, Skills, and Abilities:
Knowledge of computer applications such as Microsoft Office, Insights and other Business and Financial systems
Electronic Medical Record and Coding
Must be able to read, write, speak and understand English
Meditech experience is preferred