EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:

High school diploma or equivalent required. Bachelor’s degree with specialization in health information administration preferred.  Four or more years' experience managing/supervising a medical record department required.   Two or more years’ of behavioral health experience preferred. Working knowledge in ICD-10-PCS and DSM IV coding systems required.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

Registered Health Information Technician (RHIT) required or ability to obtain within six months of hire date. Registered Health Information Administrator (RHIA) preferred.

ESSENTIAL FUNCTIONS:

Maintain department productivity, quality and efficiency for all processes within the department. Responsible for information governance to ensure facility-wide health data integrity, privacy, and security. Implement processes and systems to support accurate and complete medical record documentation. Oversee and assist with data collection, storage, retrieval, assembly, analysis, filing and retention of medical records/data. Prepare and analyze clinical data for research purposes, process improvement, utilization management, mandatory reporting, and more. Provide staff management to including hiring, development, training, performance management and communication to ensure effective and efficient department operation. Work with physicians to improve the quality of documentation. Work with coding staff to ensure accurate coding for reimbursement and clinical care. Oversee data collection, storage, retrieval, filing and retention of medical records/data. Audit records and data for accuracy, compliance and timeliness. Review results with administration, medical, nursing and clinical staff. Ensure documentation is filed in the medical records in an accurate and timely manner and ensure that the medical record is complete (including signatures) and closed within facility guidelines. Interface with inside/outside legal counsel regarding content of medical records. Work as liaison between facility and transcription vendor to ensure high quality, accurate, complete and timeliness of transcribed documents. Ensure HIM Key Indicators are tracked and reported monthly to the Performance Improvement Committee. Ensure State Reporting is accurate, complete and reported timely. May oversee and/or complete coding according to current ICD and/or CPT coding classifications. May serve as the facility Privacy Officer.